Monson Retirement Home

A registered manager was not in place and the provider's senior management team, had day to day responsibility of the service. A new deputy and manager had been recruited and were due to commence.

The provider had and continued to experience, staff recruitment and agency staff difficulties. The provider had taken all reasonable action to address these issues and some improvements had been made. Whilst the provider used a dependency tool to assess staffing requirements, concerns were identified with the safe staffing levels the provided had risk assessed for. The provider agreed to ensure the optimum staffing levels they had assessed as required were consistently met. Following the inspection, the provider submitted staff rotas to confirm this.

The provider had safe staff recruitment checks and staff received ongoing training and support.

Risks associated with people's care needs had been assessed and were regularly monitored. A new electronic care record system was being introduced and people's care plans and risk assessments were all being reviewed. A sample of the new care records were found to be more detailed and person centred. The provider had a short time scale to complete these reviews.

The provider had systems and processes that regularly monitored the health and safety of the premises, equipment, and the environment. Fire safety remedial action had been completed and some refurbishment and redecoration work had been completed since the last inspection and this was ongoing. Incidents were analysed for themes, patterns, and any lessons to reduce further risks.

Infection prevention and control measures overall followed best practice guidance. Some practice issues were identified in how soiled laundry and mop heads were managed. The provider took action to address this. People who used the service, relatives and a visiting professional were overall complimentary about the approach of staff, who they described as being kind, caring and attentive. Concerns were raised about changes within the management team and people were looking forward to having a stable and effective management team.

The providers senior leadership team had day to day responsibility and development for the service. There

was ongoing oversight with clear roles, responsibilities, and accountability. However, this needed to be improved upon within the staff team, to ensure the provider's policies and procedures were consistently followed.

The provider had used and improved, systems and processes that monitored the safety and quality of the service. A robust improvement plan was in place that reflected the shortfalls identified during this inspection. People, relatives and staff received opportunities to share their experience and feedback about the service. The provider took positive action in response to feedback received to make improvements.

Staff had developed positive partnerships with external health and social care professionals to support people to achieve positive outcomes.