critical“No best interests decision was recorded in relation to the splints...there was a risk the service may not have identified restraint was happening.”
moderate“The service did not always assess people's mental capacity to make particular decisions, or did so in a way that did not meet legal requirements.”
incident learning
1 finding
critical“The provider had not notified CQC of at least 14 notifiable incidents...This meant CQC was not aware of incidents that might have affected the way we monitored the service.”
governance
1 finding
critical
“Systems and processes had not enabled the registered managers to assess, monitor and improve the quality and safety of the service.”
person centred care
1 finding
moderate“Agency staff who did not know people well and were not as attentive to their individual needs and preferences as regular staff.”
safeguarding
1 finding
moderate“The safeguarding adults policy reviewed in November 2022 referenced outdated national and local policies and guidance.”
communication with families
1 finding
minor“Relatives had mixed views about how well staff kept them informed from day to day...Communication is not good. We used to get newsletters, that all stopped.”
complaints handling
1 finding
minor“The complaints policy wrongly instructed complainants to escalate their complaints to CQC, which does not have the legal powers to investigate individual complaints.”
record keeping
1 finding
minor“A relative highlighted how they had alerted the service to incorrect contact details for a close family member...The quality assurance checks should have identified this but had not.”