minor“some chair covers on dining chairs were ripped and chairs required re-covering. Additionally, flooring in the dining room required replacement.”
safeguarding
1 finding
critical“The provider had failed to adequately protect people from the risk of abuse. This was a breach of Regulation 13 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
incident learning
1 finding
critical“The provider had not made the required statutory notifications to CQC in relation to safeguarding incidents which had taken place at the service.”
governance
1 finding
critical“Action had not been taken to mitigate the risk posed to people and staff at the service...breach of Regulation 17 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Good governance.”
person centred care
1 finding
critical“People's individual needs were not always being met...breach of Regulation 9 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Person-centred care.”
staff training
1 finding
critical“Staff had not been trained in this area...struggling to manage some of the behaviours. One staff member said, 'I think we need more. I don't think we have the training we need. Nothing around restraint.'”
staffing levels
1 finding
moderate“Staff's time was often taking up managing one person's behaviours and this restricted the amount of time they were able to spend with other people.”
communication with families
1 finding
minor“People were not always given information in ways they could understand...food menus were in small type face and would be difficult to read and understand for people who used the service.”
leadership
1 finding
moderate“There had been a lack of action to address this by the provider and the registered manager...had not been adequately acknowledged or addressed by the registered manager or the provider.”