critical“The provider did not have service level policies, systems and processes in place to manage safeguarding concerns. There was limited oversight of all safeguarding concerns raised.”
governance
1 finding
critical“Systems and processes did not assess, monitor and improve the quality of the service or mitigate the health, safety and welfare of the people who use the service.”
incident learning
1 finding
moderate“The registered manager was not able to establish how lessons had been learnt from all incidents and how investigations had been used to drive quality.”
care planning
1 finding
critical“People who were at risk of wandering did not have care plans or risk assessments in place to support staff and ensure people's safety.”
staff training
1 finding
moderate“Staff were supporting people who were diabetic, however they had not received training in diabetes management. A relative said, 'The staff don't seem to have any training around the physical side of caring.'”
record keeping
1 finding
moderate“People's care records were not fully completed or up to date. Care plans and risk assessments should reflect differing stages of dementia with differing risks.”
leadership
1 finding
moderate“The provider did not have service level policies and procedures in place to guide and support staff. Managers and staff were unclear about their responsibilities.”
person centred care
1 finding
moderate“Care plans did not reflect the specific changing needs over time of someone living with dementia. Relatives said, 'Staff do not seem to understand dementia.'”