During an assessment under our new approach
Date of assessment: 30 April 2026 to 1 May 2026
We inspected this service due to concerns identified around risk management, care planning, and mitigation of foreseeable harm, particularly around unexplained injuries, falls prevention, clinical monitoring and environmental safety. Since the last assessment the provider has changed.
We found the provider was in breach of the legal regulation relating to consent, safe care and treatment, good governance and staffing.
Governance systems were not consistently effective in identifying, assessing and mitigating risks to people. We found repeated shortfalls across key areas including medicines management, risk assessment and management, safeguarding oversight, staffing deployment, infection prevention and control, and environmental safety. Although some risks had been identified through internal processes, we found these were not always acted upon in a timely or effective way, resulting in continued exposure to potential harm for people.
Systems for monitoring quality and safety were not robust. Audits and quality assurance processes did not consistently identify or address shortfalls, and where issues were identified, there was limited evidence of sustained improvement. Lessons learned were not consistently embedded into practice, and action plans did not always demonstrate clear completion or sign-off. This meant the provider could not demonstrate effective oversight of the quality and safety of the service.
We found that staffing arrangements were not always effectively planned or deployed to meet people’s needs. Monitoring of staffing effectiveness and dependency levels did not always take account of call bell demand, incident trends or periods of increased risk. This resulted in inconsistent assurance that sufficient staff were always available to meet people’s needs in a timely way.
Although some immediate actions were taken during and following the inspection in response to identified risks, these were at an early stage of implementation and had not yet been embedded or tested for effectiveness. As a result, the provider could not demonstrate sustained improvement in the quality and safety of the service.
We have asked the provider for an action plan in response to the concerns identified at this assessment relating to consent, safe care and treatment and staffing.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.