Updated 17 May 2024
Date of assessment: 30 June 2024 to 30 August 2024 We assessed the service due to concerns we had received from external agencies relating to people’s safety, risk management and governance. We initially looked at 7 quality statements, however, the assessment was later expanded to include a further 6 quality statements following concerns identified at our initial onsite visit. Risks to people were not managed effectively and processes for calculating staffing levels had not recognised the individual needs of people at night-time. Staff had not received appropriate training to meet people’s needs safely and effectively and as a result people were placed at risk of harm. Safeguarding concerns had not always been dealt with appropriately. The provider did not promote effective partnership working. Decisions were made for people who lacked capacity which did not follow national best practice guidelines and legislation. Leaders did not promote a culture where people’s dignity was respected. There was a lack of oversight within the service and leaders did not have the skills to ensure the service ran safely. Systems and processes to ensure people received safe care were not always effective. We identified 5 breaches of the legal regulations in relation to safeguarding, safe care and treatment, consent, dignity and respect, and good governance. 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 some of the concerns found at this assessment.