The home recently completed its Direct Monitoring Assessment, the contents of which are recorded below.

We have reviewed the information and data made available to us about your service on 20/06/2023.

We consider that no further regulatory activity is indicated at this time. We reserve the right to keep this under review, and it may be subject to change. Please note this is not an assessment for the purposes of section 46 of the Health and Social Care Act 2008.

This monitoring activity is part of our Monitoring Approach 22/23 and is not an inspection.

Monitoring summary records are not inspection reports and are not published on our website. They are an account of our monitoring activity. We do not expect them to be shared publicly to give assurance on the quality of care you deliver.

This summary record outlines what we found as a result of our monitoring activity:

We spoke with the registered manager and care manager on 20 May 2023. You told us you have day-to-day responsibilities for the management of the service with support from the care manager. You are the registered provider and play an active role within the organisation. You told us twenty-eight people with assessed residential care needs lived at the service. The PIR was submitted in March 2023, which assisted with the planning of the call. We reviewed the last inspection report, which gave you an outstanding rating. You shared some of the feedback received from relatives about the care of their loved ones, which was positive. We also reviewed reviews from the website, which gave the home the highest rating in the area and included positive reviews. These gave assurances that the service is safe and well-led. You told us it was very important the service is driven by the people that live in the home.

You and the care manager ensure the governance arrangements are fulfilled by completing audits in relation to the care and management of the service. You use health and safety consultants along with HR and fire safety consultants to monitor and advise you and help maintain high standards of care. Staff meetings and daily handovers are used to share information about people’s care and the expectations of you and the care manager. You said, “You employ good people,” which ensures they are passionate about the care and support they provide.

You told us there was no ongoing safeguarding, but you would work closely with the local authority safeguarding and monitoring teams if required. You told us how lessons had been learned, which has improved how you monitor people’s skin integrity by completing waterlow audits.

Staff have received refresher training in safeguarding. You are assured staff are responsive to people’s needs. You and the care manager do walkarounds and observe staff supporting people. The care manager can also cover care shifts if needed to monitor if staff are being respectful and maintaining people’s dignity. You also monitor how long call bells are sounding which indicates the time people are waiting for assistance. The care manager told us pagers are also used to monitor call responses.

Team leaders and senior staff have responsibility for the safe management of medication. Regular auditing by yourself and the care manager ensures medication is administered safely and errors are swiftly identified. Staff have received training and have their competencies checked regularly.

You told us end-of-life care plans include essential information about people’s advanced wishes. This may involve relatives where people have limited cognitive ability to express their final wishes. You told us you have support and advice from DN and GP and have a dedicated phone line for additional support. You told us the service ensures people consent to their care before staff provide personal support. Staff have received training to understand the importance of consent and preferences when supporting people with their care.

Robust risk assessments are developed alongside person-centred care plans and reviewed regularly to ensure they reflect people’s needs.

You told us how you engage with health and social care professionals to support people using the service. Referrals to health professionals such as the SALTs and dieticians help manage people who are at risk of losing weight. You monitor accidents and incidents, enabling you to identify trends where people may need to refer to the falls team. During the pandemic, you found staff were upskilled and more confident when identifying if people’s health was deteriorating.

You told us the staff retention is very good with only three staff leaving the service in the last twelve months. You feel there is always enough staff to meet people’s needs.

You told us you value the staff who work at the service and provide Monitoring Summary Record 3 champions in EOL care, nutrition, dementia, IPC, and several other topics.

Staff receive regular supervision and are given time to discuss their development and any concerns they may have. You told us training in all mandatory subjects is available for staff to complete. This includes training such as how to move people safely and fire evacuation. There is a comprehensive induction programme for new staff, and you told us you look for new staff with the attributes needed to deliver good quality care.

Staff received additional IPC training, which included the wearing of PPE. You told us you continue to follow IPC guidance which includes the optional wearing of face masks etc, and testing staff and service users if they have covid symptoms.

Activities are arranged following consultation with the service users, such as walking groups, Church services and a memory tree to remember friends. The home was able to celebrate the King’s coronation, which was an enjoyable day.