critical“The person's care plan included information about their care and support needs, however, we found these were lacking in personalised information about their preferences.”
record keeping
1 finding
moderate“There was no recorded information about their likes and dislikes in relation to their food.”
governance
1 finding
critical“The provider had not identified they were delivering Personal Care and had not informed CQC that they were delivering Personal Care during a period of time in which they had declared themselves to be dormant.”
person centred care
1 finding
moderate“Care plan audits had been completed for the person in receipt of a regulated activity in September 2023 and these indicated there were no issues in their care plan.”
safeguarding
1 finding
critical“The provider did not always assess risks to ensure people were safe. Staff did not always take action to mitigate any identified risks.”
incident learning
1 finding
moderate“Systems were not robust enough to demonstrate service improvement was effectively managed. This was a breach of Regulation 17.”
leadership
1 finding
moderate“The registered manager and other senior staff were not always clear about their responsibilities in the running of the service.”
other
1 finding
minor“The provider did not fully understand their responsibilities under the duty of candour.”