The Lowedges

No accidents, incidents or safeguarding concerns had been reported at the time of the assessment. Since our last assessment new systems and processes had been implemented to record, monitor and learn lessons from incidents. Appropriate safeguarding policies and whistleblowing procedures were in place, and staff had received safeguarding training. The service was not supporting anyone who lacked capacity under the Mental Capacity Act (MCA) 2005 at the time of the assessment.

A new care planning system had improved the recording of people's needs and wishes, making information more accessible and easier to share with healthcare professionals and other partner agencies when required. Although some pre-admission information was still missing, overall documentation and care planning had improved. Risks to people were effectively managed through individual risk assessments and care plans, including support around falls prevention and maintaining skin integrity. Environmental risk assessments were also completed to help ensure safe care delivery, and staff had received fire safety and evacuation training.

Improvements had been made to staff recruitment records, with police record checks and employer references obtained where possible. However, some historic gaps remained, including missing application forms and induction records that could not be obtained retrospectively. There were sufficient suitably trained staff, and new systems were being introduced to monitor call times and ensure people received their care as planned. Daily care records were also reviewed to monitor the support provided.

Infection prevention and control measures were in place, supported by staff training and spot checks to ensure safe practice. Although staff were not currently administering medicines, the provider had appropriate policies, procedures and training in place should this be required in the future.

Since our last assessment the provider had introduced new values for the service and improved leadership. Leaders had introduced new systems, undertaken additional training and brought in external support to strengthen compliance and governance. Staff had opportunities to raise concerns through supervision and meetings, although we were unable to gain staff feedback during this assessment. Equality and diversity training and professional development support were in place. Governance had improved through regular audits, quality monitoring systems and business continuity planning. New digital systems and an ongoing improvement plan had helped address previous concerns we found. Overall, our assessment found that the service had made positive progress, with stronger systems, improved oversight. However, As the service was supporting a small number of people and had experienced no incidents, complaints or safeguarding concerns during the assessment period, many of the new systems had limited opportunity to be fully tested in practice. These systems will need to be embedded and sustained over time, particularly if the service grows and supports more people and employs additional staff.