critical“Some risk assessments were generic and did not reflect individual's needs. Some risk assessments did not contain people's names, and some held incorrect names.”
critical“Within each person's care plan file there was an environmental risk assessment. Each one was blank.”
governance
2 findings
critical“The provider had failed to have robust systems and processes to assess, monitor and improve the service.”
moderate“The provider had not notified the CQC when they had experienced a significant COVID-19 outbreak resulting in a very high level of staff absence”
staffing levels
2 findings
moderate“Staffing is a huge issue. There aren't enough staff to support [Name] to undertake activities”
moderate“Some staff had left recently and the remaining staff team were stretched to ensure sufficient staffing levels were maintained.”
person centred care
1 finding
moderate“Terminology within some documents was outdated and not person centred. This was mostly within documents used to describe people's behaviour and relating to continence needs.”
communication with families
1 finding
minor“Documents were not all available in formats suitable for people supported. For example; pictorial or easy read.”
supervision appraisal
1 finding
minor“Not all staff knew who their supervisor was due to the number of recent staff changes at the office.”
record keeping
1 finding
moderate“out of date language relating to people's health conditions, missing names on documentation and incorrect names on documents.”