critical“Care records lacked guidance to ensure people received consistent and safe support. Risk assessments had not been fully completed for all potential risks to people's health and welfare.”
governance
1 finding
critical“Checks and audits were not consistently robust. Some of the shortfalls found during the inspection had not been identified by the registered manager and management team.”
record keeping
1 finding
critical“Some records were disorganised and could not be accessed easily. The provider had failed to maintain accurate, complete and contemporaneous record in respect of each service user.”
staffing levels
1 finding
critical“Full employment histories had not been obtained in the three staff files we reviewed. Gaps in employment had not been explored or explained.”
consent capacity
1 finding
moderate“Some people were living with dementia and may not have capacity to make decisions. There had been no decision specific capacity assessments recorded.”
incident learning
1 finding
moderate“On a couple of occasions, the registered manager had failed to notify CQC of events that had happened at the service.”
end of life care
1 finding
minor“People were asked about their wishes at the end of their lives, but this had not been fully recorded in their care plans.”
safeguarding
1 finding
moderate“When incidents had occurred, the registered manager had informed the local authority safeguarding team. However, they had not all been reported to CQC.”