Updated 13 January 2025
Date of assessment 20 January 2025 to 11 February 2025.
The assessment was carried out to check whether the breaches of regulation issued at our last assessment had been met.
We looked at 15 quality statements in safe and well led.
We found lessons had still not always been learnt to continually identify and embed good practice. The provider still did not always have clear responsibilities, roles, systems of accountability and good governance. They still did not act on the best information about risk, performance and outcomes. This was in relation to care plans, risk assessments, daily notes, incident reporting, medicines, recruitment practices and audits.
However, the provider ensured continuity of care when people moved between services. Staff had the required training, qualifications and worked well to provide safe care that met people’s individual needs. There had now been an improvement on how the risk of infection was assessed and managed. Staff were able to speak up and have their voices heard and there was an inclusive and fair culture for staff.
The provider was previously in breach of the legal regulation relating to safeguarding service users from abuse and improper treatment and notification of other incidents. Improvements were now found at this inspection and the provider was no longer in breach in these areas.
The provider was also previously in breach of 3 legal regulations in relation to safe and care treatment, fit and proper persons employed and good governance. Sufficient improvements were not found at this assessment, and the provider remained in breach of these regulations.
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.
We have also asked the provider for an action plan in response to the concerns relating to safe and care treatment and fit and proper persons employed.