critical“There was little evidence that staff had been provided with all the appropriate training for their roles.”
staff competency
1 finding
critical“There was not a robust effective system in place to ensure that the provider employed people who were suitably qualified, competent and experienced.”
governance
1 finding
critical“there were no audits, and incidents and accidents had not been recorded and reported. Some records were incomplete”
record keeping
1 finding
critical
“failure to maintain accurate records was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
care planning
1 finding
moderate“Care and support plans were not always accurate, personalised and did not reflect the needs of the person. The care plans we checked were incomplete”
safeguarding
1 finding
moderate“The service had identified potential abuse of one of the service users and reported this to the local authority, however they had failed to also report this to CQC.”
incident learning
1 finding
moderate“There was no process for learning from accidents/incidents, safeguarding and complaints.”
medication management
1 finding
moderate“there was no evidence that staff training in safe administration of medicines had been provided or competency checked. This presents a risk that people may receive their medication incorrectly.”
supervision appraisal
1 finding
moderate“There was no evidence of formal staff supervisions, although staff felt supported by the registered manager as they listened to them.”
complaints handling
1 finding
moderate“We did not see evidence of a complaints policy as part of this inspection. The registered manager said that they were looking to put in a system to monitor the handling of complaints.”
consent capacity
1 finding
moderate“there was no evidence of consent to care being documented in people's care plans. Staff we spoke to had a mixed understanding of the MCA.”
leadership
1 finding
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
end of life care
1 finding
minor“The provider was going to but had not yet included training in these areas for staff.”