Updated 17 May 2024
Date of assessment: 11 September to 5 November 2024. At our last inspection, the service was rated requires improvement. At this assessment we found the provider had made improvements to comply with 1 regulation. However, during this assessment we found 2 breaches of legal regulation in relation to safe care and treatment and governance arrangements. This means the service needs to make improvements in these areas. Our overall service rating remains requires improvement. We found areas of concern and good practice. The provider had assessed people’s care needs; however, they did not adequately assess and mitigate the risks to people’s health and safety. People’s care records were not always updated when their needs changed and lacked personalisation. It was unclear whether people’s care was being monitored and reviewed. People’s medicines were not always managed safely. Safety checks of people’s equipment were not robust. The provider failed to demonstrate clear oversight of incidents, accidents, and safeguarding concerns. There were insufficient systems to support oversight and governance at the service. Not all areas of the service were being audited and for those areas that were, the provider had failed to identify and address the issues we found during this assessment. Staff had not received training to meet people’s specialist care needs. The provider had not ensured safe recruitment practices were consistently followed. The provider failed to manage the risks of staff working alone. Records of staff and management meetings indicated a lack of reflective practice, learning and actions. People were supported to have maximum choice and control of the lives. There were enough staff in place to meet people’s needs. Staff felt supported by the provider. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.