South Collingham Hall

We found significant failings in safety, leadership, governance, and oversight. Risks to people were not consistently identified, assessed, monitored, or mitigated, resulting in people being exposed to avoidable harm.

Care records, risk assessments, and care plans were often inconsistent, incomplete, or not updated to reflect people’s current needs. Safeguarding processes were ineffective, with some concerns not appropriately reported or escalated. The provider could not demonstrate that legal requirements relating to mental capacity, best interest decisions, and Deprivation of Liberty Safeguards (DoLS) had been consistently met.

Environmental and infection control risks were present, including trip hazards, strangulation risks, poor cleanliness, and damaged surfaces that could not be effectively cleaned. Staffing levels, particularly at night, were insufficient to meet people’s needs safely, and not all staff had received the training required to carry out their roles effectively.

Medicines were not always managed safely, with concerns relating to storage temperatures, PRN medication protocols, prescribed creams, and systems for monitoring the administration of time-critical medicines.

The provider lacked effective leadership, governance systems, and managerial oversight. Audits and quality assurance processes failed to identify serious concerns, meaning opportunities to improve care and safety were missed. There was no effective learning culture, and incidents, safeguarding concerns, and risks were not consistently reviewed, investigated, or used to drive improvements.

During the assessment, many of the concerns identified were fed back to the provider, who took immediate action to address some of the most significant risks. However, the overall findings demonstrated a service that required substantial improvement to ensure people received safe, effective, and well-led care.

We identified 3 breaches of regulation relating to safe care and treatment, safeguarding and good governance.

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.