Aim Up

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection, we rated this key question as good. At this inspection, the rating has changed to requires improvement. While people did not raise any concerns in relation to their care and safety, some concerns were raised by relatives and professionals. Further improvements were needed to the way the service analysed incidents and accidents, some of the provider’s policies, the safe recruitment process, people’s records of care delivered and the way people were supported to maintain their environment to be clean and safe. Most of these concerns were known to the provider and the service had an action plan. Further time was needed for the provider’s actions to be embedded and sustained so we can judge the impact they have on the quality of care people receive. The service had care plans to support people to manage their risk and the service used strategies to prevent distress to people. Reactive strategies for individuals were available and followed by staff, so they consistently supported people when they became distressed.

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant we identified some shortfalls with the governance of the service. The provider was not always notifying the CQC of incidents in the service. This was a breach of regulation. The management team had identified shortfalls in the service and were aware of concerns from relatives and professionals. They had developed an action plan. Some improvements had already been implemented however, further time was needed for the actions to be embedded so their effectiveness can be assessed in line with current best practice guidance right support, right care, right culture. Some of the shortfalls we identified during the assessment had not been identified by the provider. This was a breach in legal regulation in relation to good governance.