critical“The provider had not ensured effective processes were in place to assess, monitor and improve the quality and safety of the service. Breach of Regulation 17 (Good governance).”
incident learning
1 finding
critical“The registered manager did not always notify CQC, as required. They had notified us when people had died but not after key safeguarding concerns.”
safeguarding
1 finding
critical“The local authority told us the recent safeguarding alerts by partner agencies, rather than the service.”
medication management
1 finding
moderate“Not everyone had a clear care plan outlining what support they needed to take their medicines or who was responsible for ordering medicines.”
care planning
1 finding
moderate“The local authority had highlighted in an audit in 2021 the concerns we found during our current inspection with medicine care plans and the monitoring of visit times.”
person centred care
1 finding
moderate“Care was not always holistic and person-centred. A common theme from feedback we received was care provided by some staff was task focused.”
communication with families
1 finding
moderate“[Person] has a health need which started about 2 months ago, not one of the carers told me about it and they didn't alert the District Nurse either.”
infection control
1 finding
minor“We had feedback from relatives that some staff were not cleaning as required. This increased the risk of infection.”