critical“The failure to establish effective systems to assess, monitor and improve the quality and safety of the service and mitigate risks was a breach of Regulation 17”
incident learning
1 finding
critical“The provider did not complete any analysis of accidents and incidents to identify areas of concern and use this information improve the safety of the service.”
safeguarding
1 finding
critical“Systems and processes to safeguard people from the risk of abuse were ineffective.”
leadership
1 finding
critical“There was no oversight by the provider or registered manager in relation to the quality and safety of the service.”
record keeping
1 finding
critical“The provider had failed to notify the CQC of multiple reportable incidents including allegations of abuse.”
missed or late visits
1 finding
moderate“People told us that their care visits were often late and felt this was down to a lack of staff.”
staffing levels
1 finding
moderate“Relatives told us they had been asked to step in to provide care when staffing numbers were low.”
care planning
1 finding
critical“The provider had not altered risk assessments in a timely manner following incidents, placing people at increased risk of harm.”
staff training
1 finding
moderate“The provider were unable to produce records to confirm staff had received appropriate training in the safe care and support for people with a percutaneous endoscopic gastrostomy (PEG).”
other
1 finding
critical“Medical attention was not always sought in a timely manner following falls, placing people at increased risk of harm.”