critical“The registered manager did not operate effective quality assurance systems to oversee the service. They had not identified the concerns we found through their own monitoring systems.”
safeguarding
1 finding
critical“We were alerted to one incident where a safeguarding alert was not raised to ensure it was investigated properly. This incident was not reported to CQC.”
medication management
1 finding
critical“We looked at the MAR sheet and the information about each medicine was noted. However, there were no signatures to indicate the medicine had been given.”
staff competency
1 finding
critical“The registered manager did not have appropriate training to carry out these assessments. This meant the registered manager could not assure us staff were competent.”
staff training
1 finding
moderate“The training matrix did not show the dates of the training so we could not judge if the staff were up to date with their necessary training.”
record keeping
1 finding
critical“Records were not always completed accurately or updated when necessary. The registered manager did not always ensure people and staff were protected against the risks of unsafe or inappropriate support.”
care planning
1 finding
moderate“One person had issues with mobility, balance and coordination...it was not explained what that position would be and how to achieve it.”
incident learning
1 finding
moderate“It was not very clear if themes and trends were identified and discussed with the staff team to ensure the quality of care could be improved.”
consent capacity
1 finding
minor“Care and support records for one person were signed by the family members and it was not clear if they had a legal right to do that.”
leadership
1 finding
critical“The registered manager did not demonstrate integrity and transparency when they failed to inform us about an incident they were responding to during our inspection.”