Creedy House

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care, which meant the legal requirement for safe care and treatment had not been met. Lessons were learned when things went wrong, however actions to embed the lessons learned were not always robust. Some staff had not completed all the relevant training to be able to meet people’s needs safely, this evidenced the legal requirement for staffing had not been met. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. There was a plan in place to make sure staff had ongoing support in the form of supervision and appraisal meetings. Staff were recruited safely. There were enough staff to support people safely. Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff knew people well and were able to identify changes to health and identify care and support needs. Accidents and incidents were reviewed and actioned by the management team, safety checks undertaken by staff. The provider had systems and processes in place to detect and control potential risks in the care environment and processes in place to assess and manage the risk of infection. We observed some infection control issues during the assessment, however these were dealt with. We were assured that the provider was working to improve safety through the layout and hygiene practices of the premises.

People were involved in their assessments and care planning processes. Before people moved into the service their needs were assessed. Care plans were in place which detailed people’s care and support needs but these were missing essential information about their clinical needs in relation to health conditions. This evidenced that the legal requirement in relation to person centred care had not been met. The provider had systems and processes in place to meet people’s nutrition and hydration needs. People told us the service worked with GP’s and health professionals to meet their health needs. The provider had a clear process in place to escalate health concerns. Staff had a good understanding of meeting people’s changing needs.

People were not always treated with respect and kindness. For example, we observed a staff member waking up a person by putting on their apron without explaining what was happening or giving them time to adjust to being woken up. This was an area for improvement. However, we did see positive interaction as well. People’s cultural and religious needs were not always respected, we reported this to the registered manager who made changes to ensure people’s religious needs were better met. The provider had systems and processes in place to promote and support staff wellbeing. Staff gave us mixed views about the support they received. We assessed a limited number of quality statements in the caring key question and found areas of good practice and concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains good.

The management team told us that they and the service were looking at ways to continually improve. Accident, incidents, complaints or other significant events were logged on an electronic system. The management team used this to analyse trends and patterns, this analysis had not always been fully robust as times of day had not been identified for some incidents and accidents and part of the documentation was missing. Systems and processes to audit and check the service were in place, however these were not always robust. This evidenced that the legal requirement in relation to good governance had not been met.