moderate“Due to the relatively short time frame since the last inspection, we were unable to evidence the improvements were truly embedded and systems of governance were consistently robust, reflective and transparent.”
critical“There were no formal audits of the systems enabling the provider to monitor the service such as care plans, medicines, recruitment of staff and service delivery audits.”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post. A new manager had been in post for around 6 weeks and planned to apply to register with CQC.”
moderate“Since May 2022 there had not been a registered manager... the senior management team had not visited the person receiving the service to ensure ongoing compliance since July 2022.”
incident learning
2 findings
moderate“The provider had not always been proactive in identifying potential concerns and taking appropriate actions to improve or mitigate risk.”
critical“The provider had failed to notify us of two incidents that were reportable to the Care Quality Commission... an incident where the police were involved and the other related to the loss of staff recruitment and training records.”
safeguarding
1 finding
critical“An allegation was made about physical abuse of a person by a member of staff. Other professionals asked the provider to investigate the allegation, but they were not confident in the initial investigation.”
staff competency
1 finding
moderate“Two professionals felt staff knowledge and training were insufficient. One said they had, 'grave concerns' about the service.”
communication with families
1 finding
minor“Comments included, 'The management and their communication is really awful'... 'communication had been variable'.”
medication management
1 finding
critical“People could not be assured their medicines were managed safely. This had not been recorded on the electronic medicines record (MAR)... One of the medicines on the MAR did not include the dose.”
staff training
1 finding
critical“Not all documentation was in place prior to a member of staff starting work, such as a Disclosure and Barring checks (DBS).”
record keeping
1 finding
moderate“The provider told us they had lots of contact with the staff and a team meeting, but this had not been recorded.”
complaints handling
1 finding
minor“When we discussed some concerns raised by the person's relative about meal choices... This had not been logged as a complaint or a concern in relation to the care of the person.”