moderate“The provider had not consistently notified CQC about significant events such as incidents, accidents and where there were restrictions placed on people's live.”
critical“Audits were conducted, but prompt action was not always taken to resolve any issues found including staffing shortage and the environment.”
critical“Audits and checks had not identified the lack of window restrictors in some first floor rooms.”
infection control
3 findings
minor“The infection prevention control audit had not identified two dining room chairs had damaged outer covers”
minor
“There was no ventilation in the laundry room.”
moderate“Staff told us they felt that cooking in the kitchen immediately after being on cleaning duties throughout the service, could provide an infection control risk.”
leadership
2 findings
moderate“The service had no registered manager. The provider told us a suitable person had been identified but the appointment was not confirmed.”
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
staffing levels
2 findings
critical“On the day of our inspection, staffing levels were not sufficient to meet people's needs. Some staff had called in sick, and replacement staff had not been found.”
critical“The provider failed to ensure that staffing levels met people's individual assessed needs. Funding made available by the local authority for individuals was not being utilised”
record keeping
1 finding
minor“it was difficult to establish when they were last reviewed as none were dated”
care planning
1 finding
moderate“The changes made to people's care plans and the DoLS care plans were not always clear for staff to follow.”
person centred care
1 finding
moderate“We saw people sitting in the communal area for long periods of time without any interaction from staff, who were busy with other tasks.”
communication with families
1 finding
moderate“major building work had begun at the service, but people were not consulted about it by the provider, and staff had not had time to prepare for any disruption”
other
1 finding
critical“Not all of the windows on the first floor of the building had window restrictors on them... A door to an outside area was fully accessible to residents, and led on to a small building site”