critical“The registered manager had not always acted in a transparent and candid way... they denied that this would ever take place. However, during the inspection the registered manager admitted they had smoked.”
critical“The registered provider had not ensured that effective systems were in operation to monitor and improve the quality and safety of the service. Continuing breach of Regulation 17.”
safeguarding
1 finding
critical“The Provider had failed to report an allegation of abuse in line with the procedures agreed by the local Safeguarding Adults Board. This is a breach of Regulation 13.”
incident learning
1 finding
critical
“Not all incidents where alleged abuse had taken place were shared with the local authority safeguarding team.”
care planning
1 finding
moderate“A weekly urine test should be carried out... despite the test being recorded in the person's care plan as needed to be carried out, this was not recorded.”
leadership
1 finding
moderate“Staff felt that some senior members of staff did not carry out their roles fully and that there was an inconsistent approach to managing staffing issues.”
record keeping
1 finding
moderate“The registered manager failed to tell them that as a result of one incident, one person suffered an injury that had to be attended to by one of the nurses.”