critical“care plans and risk assessments needed more information to give staff clear guidance for managing people's known healthcare risks so safe and consistent care could be provided.”
staff training
1 finding
critical“training had been provided to staff in June 2023 after the care had started in November 2022. In addition, the registered manager had still not completed learning disability training.”
record keeping
1 finding
critical“the only DBS check on file was dated June 2023. The provider stated checks had been made at the time of employment, there was no written record of this.”
governance
1 finding
critical“Systems in place to assess, monitor and improve the quality and safety of the services provided were not always effective. This was a breach of Regulation 17.”
consent capacity
1 finding
moderate“staff had not received MCA training from the provider, therefore we could not be assured that all staff had a good understanding of the MCA and how it impacted people's care.”
staffing levels
1 finding
critical“recruitment processes were not robust to ensure safe and effective recruitment... no references held on file for 1 member of staff.”
complaints handling
1 finding
moderate“the registered manager told us they had received no complaints; however, we were aware of 1 complaint that had been shared with CQC... a record of this had not been completed.”
leadership
1 finding
moderate“The registered manager needed to improve their knowledge and understanding of their role and responsibilities including their duty to submit statutory notifications.”
medication management
1 finding
moderate“The provider told us they had arrangements in place to monitor medicines, however as there were no records of checks made, we could not verify this.”