critical“Systems had not been established to ensure safe recruitment. This placed people at risk of harm. This was a breach of regulation 19”
critical“There were irregular tests of fire alarm systems to ensure systems were working properly. At the time of the inspection, there was no fire risk assessment in place.”
governance
1 finding
critical“Audits failed to pick up the lack of appropriate risk assessments around people's personal risks... breach of regulation 17”
care planning
1 finding
moderate“Care plans were not person centred. There was information on what people needed but no information to explain to staff how could support people to achieve that goal.”
staff competency
1 finding
moderate“there were no records of staff competency following medicines training to ensure staff understood how to safely administer medicines”
record keeping
1 finding
moderate“Application forms were not always fully completed. There were gaps in applicant's employment and education history with no documentation”
safeguarding
1 finding
critical“People's known risks were not adequately assessed. This included a significant risk around a person's mental health... lack of guidance for staff”