Mountjoy Road

“The assessment was carried out in line with CQC’s assessment priorities, age of rating. The assessment commenced on 16 June 2026 and was completed on 17 June 2026. Site visits took place on both dates and included an out of hours visit.”

“Oversight at the service was not robust and quality assurance systems and processes were ineffective in identifying and addressing shortfalls. We identified concerns during the assessment in relation to risk assessment and management; record keeping and medicines management.”

“Risks to people were not accurately assessed, monitored and mitigated. People did not have care plans and risk assessments in place in relation to their specific health concerns. There were no care plans or risk assessments in place in relation to people’s Deprivation of Liberty Safeguards (DoLS) and not all staff knew who had DoLS in place. This meant there was a lack of guidance in place to enable staff to support people safely, placing them at risk of harm.”

“Medicines were not always managed safely. Protocols for medicines that were taken ‘when required’ were not person centred and did not provide sufficient information on how these were to be administered safely, or how to manage the condition for which they were prescribed. Staff did not always receive appropriate training in relation to people’s specific needs.”

“The service was clean and homely. Safe infection control practices were in place, and appropriate health and safety checks were completed. Staff wellbeing was supported, and they felt able to raise concerns with the registered manager. There were enough staff to meet people’s needs and staff were recruited safely.”

“We identified 2 regulatory breaches in relation to medicines management and good governance.”

“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. We have also asked the provider for an action plan in response to the concerns relating to medicines management found at this assessment.”