Updated 23 September 2024
Date of assessment: 1 October to 31 October 2024. We completed this assessment due to concerns about risk management and people’s safety, being identified through analysis of information received by CQC. We found the quality of the service had deteriorated since our last inspection. We identified 3 breaches of regulation relating to safe care and treatment, consent and governance of the service. Potential risks to people’s health and welfare had not been consistently assessed and there was not always guidance for staff to follow. Medicines were not managed safely. Staff did not always feel confident to raise concerns with the management team. Staff told us they were not confident their concerns would be acted on. Staff deployment did not always support people’s safety. There was not always enough staff to meet people’s complex needs. Accidents and incidents had not been consistently analysed and action had not always been taken to reduce the risk of them happening again. The provider was not following the Mental Capacity Act when assessing people’s capacity and ability to make decisions. The systems to monitor the quality of the service were not effective. When shortfalls had been identified, action had not been taken to make improvements and the shortfalls continued. 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.