The Terrace

At this inspection the service was in breach of legal regulations in relation to consent, safe management of medicines and governance.

At the time of the assessment there was a registered manager in post, however they had taken the decision to step down from this role. The deputy manager had also very recently left and the

position was vacant. This had created a sense of instability amongst the staff team and families voiced their concerns.

Medicines were not always managed safely and effectively. Medicines were not administered as directed and people were given medicines they were allergic to. This put people at risk of harm.

Incidents were not reported and managed effectively, so we were not assured that sufficient action had been taken to prevent future occurrence and learn from these incidents.

The environment was clean throughout the home and infection prevention and control measures were effective. However, maintenance, repairs and dementia friendly personalisation was required to make the home appropriate for people living with dementia.

Staff did not have confidence in the management team to address concerns they raised. They also did not know how to escalate concerns either within the organisation or externally.

The mealtime experience and quality and variety of food for people needed improving. Whilst people’s meals were safe and in line with dietary requirements, their preferences were not met. The service was without a cook at the time of the assessment, and the recruitment process was on-going.

Activities were scheduled which included external entertainers. Staff, people and relatives felt these needed to be more inclusive and focused on well-being.

Staff knew the people they supported well. They told us they worked well as a team but there was not enough staff to respond to people’s needs in a timely and meaningful manner, beyond meeting their immediate care needs.

The provider had not taken the necessary action to safeguard people who lacked capacity to make their own decisions. This included applying for legal authority to deprive people of their liberty.

Interactions between staff and people were kind and caring. However, staff told us this was not always the case and some language staff used was not dignified.

Numerous audits were carried out regularly across the service, but these were not effective in addressing issues we found on inspection. Analysis of information for trends and themes was not always carried out or not always meaningful.

Improvements were needed to engage with people, relatives and staff to ensure their voices and opinions were heard and acted on. Staff were keen to be active participants in driving improvement but did not feel they had the opportunity to do so.

The provider was aware improvements were needed within the service, and a service improvement plan had been implemented and had an action plan was in place to addressknown shortfalls. The service was also working with the local authority quality improvement team both prior to and following our assessment.

We have asked the provider for an action plan in response to the concerns found at this assessment.