The Pastures

People's needs were documented and reviewed. Changes in needs were followed up with relevant professionals.

“People's needs were clearly documented, kept under review and where changing needs were identified these were followed up with relevant professionals.” from the report

The home was clean and well maintained. Staff followed good hygiene practices and had infection control training.

“There were good infection control procedures in place and the environment was well maintained and clean.” from the report

The provider had recruitment procedures designed to check that staff were suitable before employment.

“Recruitment processes were robust to help ensure only suitable staff were employed and records included pre-employment checks” from the report

The manager was open with CQC, the local authority and relatives when incidents affected people's wellbeing or safety.

“They were open, transparent, and quick to deal with things.” from the report

Inspectors found 60 medicines errors in six months. These included recording errors, medicines being out of stock and medicines being given incorrectly, putting people at risk of avoidable harm.

“60 medicine errors had occurred in the last 6 months which were divided into different categories including medicine recording errors, medicines being out of stock and medicines being administered incorrectly.” from the report

Care plans and risk assessments were not always followed. Inspectors also found that staff did not always follow people's diet, communication or sensory plans.

“We were not assured that people always received safe care in line with their assessed needs This was a breach of regulation 12” from the report

There were 17 full-time vacancies and 30 staff had been in post for a year or less. The use of temporary staff meant some workers did not know people's needs well enough.

“There were 17 full time staffing vacancies at the time of our inspection and 30 staff (more than half the staff team) had been in post for a year or less.” from the report

Inspectors found examples where restrictive practice was not clearly shown to be in a person's best interests or the least restrictive option. Previous safeguarding concerns about physical restraint were also being addressed.

“However, in one instance we could not see how this had been agreed it was in their best interest or the least restrictive.” from the report

Audits and surveys did not focus enough on people's experiences and safety. The provider had not effectively assessed and reduced risks linked to staffing, admissions and care quality.

“This was a failure to effectively assess, monitor and mitigate the risks relating to people's health, safety, and welfare.” from the report

Activities were not always individualised, and staff did not always communicate in ways suited to people's needs. Some people experienced repeated group activities or limited support to take part.

“We were not assured that people always received care and support in line with their preferences. This was a breach of regulation 9” from the report