Updated 30 May 2024
Date of assessment 04 June 2024. The service was rated requires improvement overall at their last inspection (published 7 July 2022). This was because we were concerned the provider did not always report safeguarding incidents to all the relevant external agencies, there was no registered manager in post and did not always operate their established quality and safety monitoring systems effectively. We undertook this responsive assessment to check the provider had followed the action plan following their last inspection to show us they had addressed all the concerns we had. We looked at the 2 key questions, safe and well-led and some of the quality statements associated with them. We found the provider had made some improvements although concerns remained. For example, action had been taken to ensure safeguarding incidents were now reported to all the relevant external agencies. Furthermore, despite the service not having a registered manager in post for well over a year, a suitably competent and experienced manager has now submitted an application to be registered with us. Although feedback from people, relatives and staff was positive, our observations and the provider's processes indicated people had been placed at risk of harm. The way the provider continues to operate their quality monitoring systems remains ineffective. These failed to identify and/or address a number of new health and safety, and record keeping issues we found at the time of this assessment. It was sometimes difficult to gather clear and consistent information, with some records not readily available, and others not accurate, complete or up to date. The provider needs to have a clearer grasp of the day-to-day management and oversight of the care home. Therefore, the provider remains in breach of regulation for Good Governance.