The West Gate

We found people were not always kept safe and there were 2 breaches of regulation. Accidents and incidents had not always been analysed for patterns and trends. Action had not been taken quickly to reduce the risk of them happening again. People had been placed at continued risk as lessons had not been learnt. Some incidents had not been recognised as potential safeguarding concerns and had not been reported to the local authority as required. Potential risks to people’s health and welfare had not been consistently assessed. Some care plans did not have consistent information and guidance for staff to keep people safe. Medicines were managed safely, and people received their medicines as prescribed. Staff followed infection control guidance and used the appropriate equipment when supporting people. There were enough staff to meet people’s needs.

We assessed the quality statement Consent to care and treatment. We found staff were working within the principles of the Mental Capacity Act 2005 and supporting people to make day to day decisions. However, when Deprivation of Liberty (DoLs) had been authorised, action had not been taken quickly to make sure conditions on the authorisations were met.

We found the management and oversight of the service had deteriorated and there was a breach of regulation. There were systems in place to monitor the service, but these had not always been effective in identifying shortfalls. When shortfalls had been identified, action had not been taken quickly to rectify them. The management had not driven improvement and learnt lessons from incidents. Quality assurance had not been completed in line with the provider’s policy. People, relatives, and staff had not had the opportunity to attend regular meetings to give their opinions of the service. Staff had not received all the training required to complete their roles. They had not received regular supervision to discuss their practice and training needs. Staff told us, they were confident to raise concerns with the management team and they were supported. The management team supported an inclusive and diverse staff team.