Christ the King, Footherley Hall

Following our last inspection, we asked the provider to provide us with an action plan to demonstrate how improvements would be made in relation to the management of people’s risks, the safe management of medicines, and the governance of the service. During this inspection we found continued breaches of regulation relating to risk and medicine management, the governance of the service and a new breach of regulation relating to the assessment of people’s mental capacity. The registered manager had not always submitted to us notifications about key events at the service. This was a breach of a registration regulation.

The systems in place were not always effective in monitoring and managing people’s risks. The care records were not always completed appropriately, which meant staff and management were not always aware of important information about people’s needs. Medicines were not always recorded in a safe way. The systems in place to assess and manage the quality and safety of the service were not always effective.

Staff understood the importance of consent and empowered people to be involved in their own care and to make their own decisions where possible, but where people lacked mental capacity, they did not have the necessary mental capacity assessments in place.

Staff knew how to recognise concerns, and worked well as a team, however, there needed to be more clear, robust processes in place to ensure safeguarding concerns were referred to external agencies where needed and there was an ongoing culture of learning and accountability.

Staff were caring and kind and supported people in a dignified way.

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.