critical“the providers safeguarding processes failed to ensure professionals were made aware of an issue to enable them to ensure one person's safety. This left them exposed to risk.”
staff training
1 finding
critical“The provider had not ensured they or staff had received updated safeguarding training to keep up to date with changes to legislation and best practice.”
governance
1 finding
critical“The provider had failed to establish systems and processes to assess and improve the quality and safety of the service provided or to assess and monitor risks.”
care planning
1 finding
moderate“Care plans did not always contain detailed information about people's health conditions and this increased the potential risk of harm.”
incident learning
1 finding
moderate“the registered manager was unable to evidence learning from incidents”
record keeping
1 finding
moderate“Records did not contain details of how this condition affected the person or actions to take in the event of a crisis.”
supervision appraisal
1 finding
moderate“Staff did not always receive sufficient training and supervision was generally informal.”
leadership
1 finding
moderate“The registered manager did not always demonstrate their knowledge of regulatory requirements. They had not always understood their duty to notify CQC of events within the service.”