What the CQC found at Wellfield

The provider had assessed and reduced ligature risks, kept staff areas locked and completed important health and safety checks.

“We found that the provider had taken action to identify and mitigate environmental risks at Wellfield.” from the report

The provider had updated its policies and procedures, and most reflected the services being provided more closely.

“Most policies and procedures better reflected the services that were provided at Wellfield.” from the report

Records of incidents and restraint had improved and included more information about what happened and how restraint was managed.

“We also found that incidents of restraint had been better documented and had included more detailed information about the management of restraint.” from the report

Risk strategies were not always effective or followed. Inspectors described incidents where the young person absconded and was exposed to an increased risk of harm.

“This placed people at risk of harm. This was a breach of regulation 13(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Direct referrals to the local authority were not made consistently and did not always include enough information about the concern or the young person's circumstances.

“Safeguarding referrals that had been made to the local authority as direct referrals had not been done in a consistent way and had not always contained enough information.” from the report

The provider could not show that all staff, agency staff and managers had completed the training needed for their roles. Only five of 11 staff had evidence of first aid training at the inspection.

“We found that staff had not completed all elements of other training that had been required.” from the report

The provider's systems did not reliably monitor quality, manage risks or make sure incidents led to learning. Two key management team members later left, including a manager.

“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17.” from the report

Some checks had improved, but personal items were not consistently signed in and out in August 2023. This could have increased the risk of avoidable harm.

“However, in August 2023, we found that this had not been done consistently in August 2023, potentially exposing the young person to an increased risk of avoidable harm.” from the report

Although a new policy was in place, the provider did not recognise or carry out its duty to be open and honest after an incident in which the young person came to harm.

“Systems had not been established to make sure that the provider acts on the Duty of Candour when needed.” from the report