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Medicine management required improvement, accident and incident oversight was not always effective as not all accidents or incidents had been reported appropriately to the relevant safeguarding authority or CQC. There was also limited information found when investigating or analysing accident information. Deprivation of liberty application and authorisation oversight was not always effective. The registered manager did report these concerns retrospectively following the assessment. There were enough staff to support people and recruitment processes had improved.

We identified a breach of regulation during this assessment of Well led. Governance and oversight systems were not always effective, and we identified concerns relating to environmental risk, accident and incident oversight, safeguarding concerns not always reported appropriately, medicines and oversight of deprivation of liberty applications and authorisations as described in other areas of this report.

The senior management responded proactively to the concerns identified during this assessment. However, at our previous inspection a recommendation was made for the provider to review their systems and processes for quality assurance to ensure more robust oversight of the service. The quality assurance processes in place were still not effective as shortfalls found during this assessment had not been identified by the provider.

Whilst improvements were needed to ensure effective oversight people, relatives and staff were positive about the way the service was run and the support they received.