Pharos Black Country

Systems to assess, monitor and mitigate risks to people, were not always robust or effective. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Where incidents and safeguarding concerns had been reported to the provider, lessons had not always been learned or improvements embedded into practice. People were not always protected from the risk of infection. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Recruitment procedures were robust, and people were supported by adequate numbers of staff.

Systems in place to assess people’s needs were not always effective. People were not consistently at the centre of their care, and care plans to guide and inform staff did not always have the information needed to ensure people received the best outcomes.

Staff were kind and caring and we saw some good interactions between people and staff. However, the systems in place did not always ensure people achieved their best outcomes.

The provider’s systems to ensure people were at the centre of their care were not always consistent or embedded across the service. There was a complaints system in place, but this had not been consistently implemented and followed. This was a breach of Regulation 16 (Receiving and acting on complaints) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider’s governance and quality assurance systems were not always effective to ensure the delivery of good quality care and support to people. Although a number of audits and checks were completed, this had not enabled the provider to identify and address a number of concerns we found during this assessment. These included shortfalls in the assessment and management of risks to people. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider responded to issues raised during the assessment and took some immediate actions. This provided reassurance about people’s safety but demonstrated a reactive rather than a proactive service. It was not evident that high-quality leadership was embedded at all levels.