Little Oldway

We identified 1 breach of legal regulations.

People were not consistently protected from the risk of harm and staff did not always make safeguarding referrals in line with the providers policy and procedures. Staffs’ approach to the management of risk was inconsistent and we could not be assured that staff had access to all the available information to support people to manage and mitigate risks to themselves or others.

We found some people were subject to blanket restrictive practices; there was no system in place for reviewing restrictive practice to ensure that any restrictions remained the least restrictive option. This meant the provider could not be assured that any restrictions were or continued to be in a person’s best interests.

The provider could not be assured that people were supported by staff who had the skills and experience to meet their needs safely.

We have made a recommendation in relation to creating a dementia friendly environment and meeting the needs of people with a sensory impairment.

However, people told us they felt safe living at Little Oldway, and relatives felt confident with the care and support provided. Other risks to people’s health and wellbeing were being managed well. Where people required specialised equipment to keep them safe, we saw this was in place and staff followed people’s individual risk assessments. People were protected by safe recruitment practices.

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

People were not always supported to have maximum choice and control of their lives and staff did not fully understand their roles and responsibilities under the Mental Capacity Act 2005 (MCA) including Deprivation of Liberty Safeguards (DoLS). However, the provider had systems and processes in place to help ensure people were supported to understand their rights and staff had received training in MCA and DoLS.

We have recommended the provider undertakes a review of all documentation relating to MCA, best interest decisions and DoLS.

We identified 3 breaches of legal regulations.

People who were able to share their views with us and their relatives spoke positively about the service, the staff and the care and support they received. However, we found the service was not operating in accordance with the regulations.

At the time of this assessment the service did not have in place a registered manager.

Governance processes provided limited oversight, were not effective in keeping people safe, protecting people's rights, or driving improvements.

Throughout the assessment, the care manager and nominated individual were open, transparent, acknowledged any areas for improvement and were keen to address any areas of concern.

Staff felt able to speak up and raise concerns with the care manager and/ or nominated individual.

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