critical“we identified a safeguarding incident, an allegation of abuse, which had not been reported to the Care Quality Commission (CQC) in line with guidance”
governance
1 finding
critical“The provider failed to notify the CQC without delay of a notifiable incident. This is a breach of Regulation 18”
complaints handling
1 finding
moderate“Complaints had not been consistently managed in a professional and transparent manner. People had not always received an apology when something could have been done better.”
incident learning
1 finding
moderate“The complaint was not initially responded to in a candid and professional manner and was not fully investigated in the first instance.”
care planning
1 finding
moderate“it was found there was no evidence of a needs assessment having been completed, in line with the provider's processes, before a person began to use the service”
supervision appraisal
1 finding
minor“Staff supervision meetings had lapsed during the COVID-19 pandemic. However, these had recommenced, and a schedule of meetings was in place.”
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.”