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People's experiences of using this service and what we found The provider did not have appropriate systems and processes in place to keep people safe. Staff were unable to demonstrate the required level of competency for their role. The service was not following national guidance for the prevention and control of COVID-19. The provider had not sufficiently assessed the person's needs. The person's risk assessment and care plan did not contain enough detailed and personalised information to ensure staff were able to provide the person with safe, person-centred care that met their needs and preferences. The provider did not learn lessons and share learning with staff when something went wrong.

The provider had not followed safer recruitment practice and staff were not recruited safely. Staff did not receive the training and support they needed to ensure they could provide safe and effective care.

The provider had not established systems and processes to effectively monitor and mitigate risks and improve the quality and safety of the service. The systems and processes that were in place were not operated effectively. The provider did not have sufficient policies and procedures in place and the policies that were in place were not suitable for a care service. The culture of the service was not person-centred.

The registered manager was not always available or contactable and they lacked knowledge and understanding about how to establish and operate the systems and processes required to ensure good governance . This meant we were concerned about whether they were able to carry on the regulated activity and manage it.

Notwithstanding the above, we found staff were kind, caring and knew the person well. Staff supported the person to live a healthier life and achieve their goals. Staff knew the person's likes, dislikes and preferences and communicated with the person in ways they could understand. The person's equality characteristics were considered, and they were well treated and their dignity was respected. The provider worked well with other organisations and professionals when it was required.

The person was supported to have maximum choice and control of their life and staff supported them in the least restrictive way possible and in their best interests.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This service was registered with us on 12 February 2019 and due to the service not providing a regulated activity for a period of time, this was the first inspection.