minor“we identified one event relating to one person which had not been notified to the CQC as required.”
critical“Governance processes were ineffective and failed to keep people safe, protect people's rights and provide good quality care and support.”
consent capacity
2 findings
minor“One deprivation of liberty order had expired. The provider produced extensive evidence of correspondence they had made in order to have this order reviewed.”
critical“The provider was not working in line with the principles of the MCA. Assessment and care planning processes did not always consider people's capacity to consent to care and treatment.”
safeguarding
1 finding
critical“Systems to protect people from the risk of abuse or neglect were not in place. Staff had not all received safeguarding training to ensure they knew how to identify and report abuse concerns.”
medication management
1 finding
critical“Medicines support plans were not in place. No guidance was available for actions to be taken by staff within a timeframe when a person refused their medicines.”
staff training
1 finding
critical“Some staff were recorded as not having completed any training relevant to their roles. Significant gaps in staff training records included safeguarding, practical moving and handling and basic first aid.”
staff competency
1 finding
critical“The provider had not identified that people were supported by staff who did not have the correct training and competency in place. For example, manual handling.”
care planning
1 finding
critical“Care and support plans did not reflect people's needs, likes, dislikes, goals or aspirations. Most people's care plans did not provide staff with clear guidance on how to meet their individual needs.”
record keeping
1 finding
critical“Records including mental capacity assessments, medicines records and staff records were not always accurate, complete and up to date.”
incident learning
1 finding
moderate“The provider did not have a process in place to analyse, identify trends or learn lessons to improve on the service provided.”
supervision appraisal
1 finding
moderate“Staff did not have regular supervision to receive feedback on their performance and constructive feedback on how this might be improved.”
person centred care
1 finding
moderate“We found the language used in some people's care plans to be disrespectful and undignified. For example, '[Name] is very childlike in their manner'.”
communication with families
1 finding
moderate“We saw limited evidence that staff meetings or meetings with people and their relatives were taking place.”
infection control
1 finding
minor“Staff had not all completed infection, prevention and control training.”