Updated 5 March 2025
Date of assessment 1 April to 15 May 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.
The provider was previously in breach of the legal regulations in relation to safe and care and treatment, and good governance. The provider has remained in breach of good governance. The provider continued not to have effective oversight of their recruitment processes to ensure safe staffing practices. Additionally, the provider’s systems to make improvements to their service were not always effective. This inspection also identified the provider was in breach of the legal regulations related to notifying CQC. We have requested an Action Plan from the provider to show us how they will comply with these legal obligations. 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.
However, some improvements were found at this assessment in relation to safe care and treatment. The provider had made improvements to ensure people’s care planning information included relevant details about their needs and any risks were managed. Staff were aware of people’s care plans and risks and new staff had opportunities to shadow experienced staff to help them understand what they needed to do.
Staff had the required training to support people safely. The provider worked well with people and health professionals to ensure people’s needs were safely met. The provider learned from incidents and shared their learning with staff and partners. Referrals were made to health professionals where required.