Updated 7 March 2024
We carried out our unannounced on-site assessments on 14 and 19 March 2024, off site assessment activity started on 13 March and ended on 26 April 2024. The assessment was prompted in part by concerns about the culture of the service. At our last inspection we rated the service requires improvement overall. At this assessment we identified 2 repeated breaches of regulation in respect of not complying with the Deprivation of Liberties procedure and recruitment practices. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We have asked the provider for an action plan in response to concerns found at this assessment. However, despite the ongoing repeated breaches of regulation, we noted there were also improvements to the service and the assessment rating has improved from requires improvement to good in safe, effective and well led. This means that the overall rating of the service is now good. We looked at 21 quality statements; learning culture; Safe systems, pathways and transitions; Safeguarding; Involving people to manage risks; Safe environments; Safe and effective staffing; Infection prevention and control; Medicines optimisation; Assessing needs; Delivering evidence-based care and training; How staff, teams and services work together; Supporting people to live healthier lives; Monitoring and improving outcomes; Consent to care and treatment; Shared direction and culture; Capable, compassionate and inclusive leaders; Freedom to speak up; Workforce equality, diversity and inclusion ; Governance, management and sustainability; Partnerships and communities; and Learning, improvement and innovation.