critical“Information of concern had not been appropriately escalated and reported to the relevant local authority where legally required.”
staff competency
1 finding
critical“The provider could not demonstrate all the required pre-employment checks for staff had been completed. This included relevant checks on staff's right to work status.”
record keeping
1 finding
moderate“There were multiple examples where people's care and medicines records were not always complete, up to date or accurate to reflect the care they received.”
medication management
1 finding
moderate“Staff lacked documents to help administer people's 'when required' (PRN) medicines. Records were not consistently in place or lacked sufficient person-centred information.”
consent capacity
1 finding
critical“Assessments of people's capacity had not been completed in line with requirements. The provider failed to demonstrate they always acted in accordance with the principles of the MCA.”
governance
1 finding
moderate“Audits completed did not identify the concerns we found at this inspection. Examples included in respect of safeguarding, medicines administration records, and consent.”
care planning
1 finding
moderate“Where a person was identified as at risk of skin integrity breakdown, their records did not include robust information on repositioning or reflect the care staff told us they provided.”
end of life care
1 finding
minor“People's care plans did not include information on their end-of-life care wishes. We raised this with the registered manager who told us they would address this.”
incident learning
1 finding
moderate“The provider had failed to ensure an incident of notifiable information had been shared with CQC in line with their legal requirements.”
staff training
1 finding
minor“Not all staff had completed end of life or diabetes training where people were supported with these needs.”