critical“when incidents of potential abuse had occurred, they had not always been appropriately reported to the safeguarding team, as required”
consent capacity
1 finding
critical“When people lacked capacity to make decisions for themselves capacity assessments and best interests decision were not in place.”
staff training
1 finding
moderate“The registered manager and staff did not demonstrate an understanding in this area and staff had not received training.”
governance
1 finding
critical
“The quality monitoring systems in place are not always effective in identifying concerns and driving improvement within the home.”
record keeping
1 finding
moderate“The system the provider had in place to record people's care was not always secure. Records were shared from staffs' personal phones to the providers data base.”
incident learning
1 finding
moderate“when incidents and accidents occurred the information was recorded on a log sheet. There was no evidence that this information was used to make changes.”
leadership
1 finding
moderate“The provider had failed to update us when they had moved from their registered office location to another address.”