Blackthorns

We assessed all 8 quality statements from this key question and found areas of concern. The scores for these areas rated this key question as requires improvement, which meant the rating of good given in our last inspection [Published March 2023] had not been maintained. We found a breach of legal regulation relating to how risks associated with people’s care were assessed. People’s risks were not always adequately assessed, managed, communicated or mitigated, which placed people at risk of potential harm. Staffing levels and staff deployment did not always safely meet people’s holistic needs and ensure staff could carry out their role effectively. The provider took action to increase the staffing levels following our feedback.

Prior to starting the assessment, we were aware of the ongoing visits and support being given from the local authority organisational safeguarding team (OST). Undertaken as part of investigating safeguarding concerns that they had received, and checking people’s safety and welfare. Although they noted improvements, and the provider had worked well with health and social care professionals to address issues, people remained at potential risk until all the changes had been made and embedded in practice. The service had systems to ensure staff were recruited safely, and people received their medicines as prescribed.

We assessed 1 quality statement from this key question. For the quality statements we did not assess, we used the ratings awarded at the last inspection (published March 2023) to calculate the overall rating of good. People were seen making choices about how they spent their day, any minor restrictions were linked to the staffing levels, which the provider was addressing.

We assessed all 7 quality statements from this key question and found areas needing improvement. The scores for these areas rated this key question as requires improvement, which meant the rating of good given in our last inspection [Published March 2023] had not been maintained. Although we received positive feedback from people and their relatives, we also identfied the quality of people’s experience varied. Shortfalls identified in people’s pre- admission assessments, care planning, and emotional and social support, impacted on the quality of people’s experiences. The provider told us they would be taking action to address this including making improvements to their pre-admission processes, and further training for staff in completing care records.

We assessed 7 quality statements from this key question. The scores from these areas rated this key question as requiring improvement, which meant the rating of good given in our last inspection (published March 2023) had not been maintained. We found a breach of the legal regulations relating to good governance. This was because the systems in place to assess, monitor and improve the quality and safety of the service were not always effective. This led to the service failing to identify concerns independently through their checks and audits, demonstrating a reactive rather than proactive culture. The provider was receptive to feedback, took immediate action to address feedback from CQC and external agencies, and provided reassurances that concerns would be addressed. Evidence observed at this assessment identified that the governance system must become more robust and integrated into staff practices and culture. Staff reported feeling comfortable speaking openly, and they felt management would listen, although some staff felt their feedback about staffing levels had not been acted upon. Staff had received training in equality and diversity, and we saw evidence of some workforce inequality being addressed by the registered manager. People had access to healthcare support if required, and the management was working in partnership with external partners to improve communication and drive improvements. We received positive feedback from people and their relatives, saying they were very happy with the care. Whilst also acknowledging areas they felt could be improved.