moderate“We were not assured processes and procedures to ensure safe recruitment at the service were in place. There were insufficient references for some staff.”
critical“The provider's quality assurance systems and processes were not effective and had not enabled them to assess, monitor and improve the quality and safety of the service.”
leadership
2 findings
moderate“The registered manager understood their role and regulatory requirements. However, we were not assured about safe recruitment requirements.”
critical“The registered manager did not always fully understand their role and responsibilities, particularly what they were required to notify CQC and local authorities about”
medication management
2 findings
critical“staff were not routinely completing Medicine Administration Records (MAR'S) when supporting people with their medicines. Therefore, it was difficult to assess if medication had been given as prescribed.”
critical“Person centred guidance was not in place for 'as required' medicines. This meant staff did not have information about the specific circumstances when these medicines should be given.”
care planning
2 findings
moderate“Care plans were not always reviewed and updated as people's needs changed.”
critical“one person's daily notes entries indicated the person wore a falls bracelet... However, there was no falls risk assessment or mobility care plan in place.”
safeguarding
1 finding
critical“we saw an example of a safeguarding concern, that was not reported to either the local safeguarding team or CQC. The registered manager and nominated individual were not clear about their role in making such reports.”
incident learning
1 finding
critical“we saw evidence not all accidents and incidents were being recorded and there was no overall analysis identifying any patterns or trends which could be addressed”
record keeping
1 finding
critical“Care records were not always complete. This meant there was not always evidence to demonstrate risks to people's health and safety were being effectively assessed, monitored and mitigated.”
end of life care
1 finding
moderate“people did not have end of life plans in place which considered their wishes and preferences. This put people at risk of receiving care which was not personalised to their individual needs and wishes.”
person centred care
1 finding
moderate“this knowledge was not always captured within care records. This put people at risk of receiving care which was not always personalised to their needs.”
complaints handling
1 finding
minor“Failure to log the informal complaint meant a missed opportunity to use lessons learnt to drive improvement to people's care.”
consent capacity
1 finding
moderate“We saw that some people's mental capacity assessments were not robust enough.”
communication with families
1 finding
moderate“People had no individual communication plans that detailed effective and preferred methods of communication”