New Partnerships Lynray and Peach Cottage

“Safe systems were not fully embedded. There was a lack of written guidance for staff to follow and gaps in staff knowledge and expertise. The provider did not ensure that staff received effective support, supervision and development. This was a breach of regulation of Regulation 18 [Staffing] of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.”

“The provider had a clear vision, but this was not translated into day-to-day practice and people did not always experience consistent care. The service had been without a registered manager for some time and whilst efforts had been made to stabilise leadership with a new appointment, it was too early to see if this was effective and brought benefits to people.”

“Governance systems were in place, but these were not effective and had not identified or addressed the issues that we found as part of our assessment. Relatives told us that there was a lack of provider foresight and despite assurances being given learning did not always take place. Risk assessments were in place however there was insufficient guidance for staff to support people who experienced distress.”

“Systems to ascertain peoples’ views were not well developed and did not align with the feedback that we received as part of the assessment. Learning from complaints was not always evident, although we saw recent examples of investigations being undertaken and poor practice challenged.”

“The shortfalls were a breach of regulation of Regulation 17 [Governance] of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.”

“People were supported to access services, and we saw evidence in care plans of consultation with a range of health professionals such as podiatry and psychiatry. People had had health action plans and hospital passports that detailed their medical needs as well as their communication needs.”

“At our previous inspection we identified a breach of regulation of Regulation 9 [Person-centred care] of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. This was because a high turnover of staff and use of agency staff impacted on the services ability to meet people’s needs. At this assessment we identified the provider was no longer in breach of this regulation as staff recruitment had improved and the use of agency staff had significantly reduced.”