Updated 14 February 2024
The assessment was undertaken in response to concerns we received of staff shortages and the provision of hot water. Off site assessment activity started on 20 March and ended on 15 April 2024. Staff were knowledgeable about their role and responsibilities in reporting concerns. Partnership working was effective in safeguarding people from potential harm and abuse. Staff recruitment practices were robust, and staff had ongoing support through training and supervision. People's care records provided a good account of identified risk and care needs. There was oversight and monitoring of DoLS (Deprivation of Liberty Safeguards) to ensure people's rights were kept under review. Audits were undertaken to monitor the quality of the care and service provided. Following our site visit the provider submitted information as to the measures they had undertaken to increase the supply of hot water and shower facilities and an action plan, with timescales, detailing the installation of new boilers and hot water system. People's needs were met, however, staff spoke of the challenges and difficulties in sometimes meeting people's needs. Contingency planning to cover shortfalls in staffing were not sufficiently robust as they relied in part, on staff from other services covering the shortfall. The provider had not considered the tool used to determine staffing levels did not factor in considerations such as the environment and people's individual needs. We have identified a breach of regulation in good governance. Systems and processes to bring about improvement did not include timescales, and were not kept under review to monitor progress. The impact of system and equipment failures on people and staff were not assessed. We have asked the provider for an action plan in response to the concerns found.