critical“The registered person had not operated effective systems to: Assess, monitor and improve the quality of the service. Regulation 17 (1) (2) (a)”
record keeping
1 finding
moderate“We identified several gaps in the recording of staff training, induction and DBS checks, confirming the managerial checks needed to improve.”
care planning
1 finding
moderate“Not all care plans reflected how people wanted to receive their care... it was not always clear who had been involved as they were not all signed and/or dated.”
staff competency
1 finding
moderate“Medicine competency checks were being conducted by the registered manager, though they did not have the correct level of training to do this.”
staff training
1 finding
minor“The provider did not always maintain clear staff induction and shadowing records. Therefore, they could not always assure us these took place as required.”
incident learning
1 finding
minor“People receiving care were asked to complete a satisfaction survey... It was not clear how this information was used. No outcomes or actions were documented or shared.”