Mr 'C's

People were exposed to avoidable risks because governance and oversight systems were not effective. Audits had failed to identify or address many of the concerns found during our assessment, including weaknesses in care records, medicines management, environmental safety, incident monitoring and notification processes. Accident and incident analysis was incomplete, complaints records were not always available, and actions identified through audits had not always been completed. The management team did not have an accurate understanding of the quality of care being provided or the risks people were exposed to.

The evidence gathered during this assessment demonstrated significant shortfalls in the systems used to assess, monitor and manage risk. Risks relating to people's health, safety and wellbeing were not always identified, assessed or mitigated effectively. Care plans and risk assessments often lacked detailed guidance for staff, were not consistently reviewed when people's needs changed and did not always reflect significant incidents or known risks.

We found concerns regarding staffing and workforce oversight. Staff reported there were not always enough staff deployed to meet people's needs in a timely way. This reduced opportunities to spend meaningful time with people and sometimes resulted in delays to care. We identified gaps in training, supervision, appraisal and competency assessment processes, with some staff lacking the knowledge and support required to meet people's needs safely and effectively.

The environment was not always managed safely. We found concerns relating to fire safety arrangements, environmental checks, maintenance records, water safety monitoring and oversight of premises risks.

There were some positive findings. Staff demonstrated knowledge of safeguarding procedures, falls management and emergency processes, and recruitment checks were generally completed. Staff spoke positively about the staff team and knew people well. The registered manager responded promptly to the serious concerns raised and took immediate action to begin addressing some of the issues identified.

We identified 5 breaches of regulation, relating to person-centred care, safe care and treatment, safeguarding, good governance and staffing. At this assessment the overall rating was Inadequate.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

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.