critical“The provider's governance and quality assurance systems were not always effective. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008.”
safeguarding
1 finding
critical“The provider had not submitted notifications about two safeguarding incidents. CQC had become aware of the incidents when notified by the local authority.”
care planning
1 finding
moderate“Risk assessments formed part of the initial assessment...however few risk reduction measures were in place for staff to follow.”
consent capacity
1 finding
moderate“Records relating to capacity needed improvement...care plans for two people suggested that both people might have fluctuating capacity...We found no evidence that capacity had been explored.”
record keeping
1 finding
moderate“Audits and checks...were not always effective as they had not identified issues we found. This included the lack of detail in risk assessments, lack of information in peoples' life histories.”
staff training
1 finding
minor“Staff had not received training on how to support people with end of life care. The registered manager told us they would ensure all staff had received training with end of life care.”
end of life care
1 finding
minor“People's wishes were not discussed or recorded in their care plans...new policy and procedure...was not in place during the inspection.”
staffing levels
1 finding
minor“Due to staff shortages across the health and social care sector the registered manager was also delivering hands on care at various times.”