critical“Recording shortfalls had not been identified through quality monitoring systems. We were not assured the provider had clear oversight of the service.”
safeguarding
1 finding
critical“Three safeguarding referrals to the Local Authority had not been notified to CQC.”
record keeping
1 finding
moderate“Accurate and contemporaneous records were not always maintained regarding people's care. This included risk assessments, medication records, food and fluid charts and communication plans.”
care planning
1 finding
moderate“Care plans provided staff with guidance on how to care for people. These were not always accurate or clear and needed updating.”
medication management
1 finding
moderate“we saw there were gaps in MARs when creams should have been applied. This had not been identified by the providers own audits.”
staff competency
1 finding
minor“Recruitment systems were in place, but needed to be more thorough when processing references, to ensure recruitment was safe.”
other
1 finding
moderate“People's food and fluid intake was not monitored and recorded effectively... There was a monthly weight chart, but it had not been completed as required.”
communication with families
1 finding
minor“the person's communication plans did not accurately reflect the detail provided in formal assessments by the Local Authority and the NHS.”