During an assessment under our new approach
Date of Inspection: 3 February to 4 March 2025. The inspection was to follow up on whether Warning Notices in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 issued at our last inspection in 2024 had been met, and to undertake a full inspection of the service under its current provider who took over in November 2023. The service has not had a registered manager in post since July 2024. The Nominated Individual (NI) was overseeing the management of the service and was responsible for supervising the management of the regulated activities provided.
The provider continued to not have effective governance systems in place to monitor and improve the quality of the service. Care planning information did not always include clear guidance around how people needed to be supported to manage risks around pressure ulcers and choking. Medicines were not always stored safely, and risks had not always been assessed in relation to blood thinning medications. Audits did take place regularly in the service; however, they continued to not be effective and had not identified the concerns we found at this inspection.
The NI had not always reported or followed up accidents and incidents with the appropriate authorities. Staff did not always report incidents that had happened to them. However, staff adjusted people’s care plans following incidents to reduce the risk of reoccurrence for people.
Staff felt there was no leadership and direction in the service. Some staff had not received supervision and told us staff meetings had not taken place regularly since July 2024.Following our inspection, the provider supplied us with evidence of meetings which had been held in August and September 2024 and January and February 2025. Morale appeared to be low for some staff members, however, staff confirmed they worked well as a team. Nurses had not had clinical supervisions to support their role and professional practices. However, staff confirmed relevant health professionals were contacted for advice around people’s health needs. The NI did not routinely seek feedback from people and staff to identify areas to improve.
The provider was previously in breach of the legal regulations in relation to safe care and treatment, good governance and staffing. 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.This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.