moderate“there were still no systems in place to monitor accidents, incidents and complaints.”
moderate“no action plan had been put into place to show how the registered manager would address this identified action.”
critical“This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 Notification of other incidents.”
record keeping
3 findings
moderate“one person's moving and handling risk assessment had not been dated or signed. We also found one person's medicines assessment was out of date.”
minor“They were not keeping a record of any complaints received verbally or informally.”
minor“We identified one gap in one staff members employment history, this was addressed during our visit by the general manager.”
incident learning
2 findings
moderate“the registered manager acknowledged they did not keep any overarching record which would identify trends or patterns in the types of concerns”
moderate“There was no central record of accidents and no overall analysis of these events was completed.”
missed or late visits
2 findings
minor“They are supposed to be here 7.15am, but this occasion it was nearly 9am and no one rang to let me know.”
moderate“"You don't know who's coming or if they're coming. It makes me feel terrible." "If they're going to be late, they don't bother to tell you"”
care planning
2 findings
minor“Not everyone was aware of their care plan and felt involved in its development.”
minor“We identified one care plans that did not contain enough detail in relation to a person's care needs and associated risks.”
supervision appraisal
1 finding
minor“the registered manager told us these [six monthly observations of practice] had not been completed as often as they would have liked.”
safeguarding
1 finding
critical“They did not report concerns about people to the local safeguarding authority as required.”
staff competency
1 finding
moderate“Where information of concern was received that required further investigation or risk assessment, this had not always been completed and recorded.”
communication with families
1 finding
moderate“"No one ever comes (from the office). I've never seen anyone", "It's important to talk to someone sometimes… say what you think of things".”
end of life care
1 finding
minor“People's end of life wishes, and preferences were not recorded in their care plans. We discussed this with the registered manager who said he would explore this with people.”