critical“There were limited systems and processes in place to ensure regular audits with action plans were taking place to improve the quality and safety within the service.”
moderate“we could not rate the service higher than requires improvement for 'well-led' because to do so requires consistent and sustained improvement over time.”
critical“The registered provider had failed to take appropriate action following our last inspection. This demonstrates inadequate management and a failure by registered provider to take action about known risks.”
moderate“Audits within the service were not as robust as they could have been... the frequency these audits took place was not clear.”
safeguarding
2 findings
critical
“Safeguarding concerns had not always been reported appropriately. Although the registered manager had a system in place to support safeguarding concerns, further work was needed.”
critical“Gloves, plastic bags prescribed creams and razors were not securely stored to help to prevent the risk of harm to people living with dementia.”
record keeping
2 findings
moderate“There was no recording of incidents within the service or regular audits of care records.”
moderate“Risk assessments for some people lacked detail and direction and behavioural support plans were not fully detailed or prescriptive.”
medication management
2 findings
moderate“we observed a member of staff administering people's medicines at lunchtime...Following administration it was noted an error had occurred.”
moderate“The storage of prescribed creams for people unsecured in their bedrooms posed a risk of harm to people especially to those living with dementia.”
leadership
2 findings
moderate“The registered manager managed two locations for the registered provider. This may have contributed to this location being inadequately managed.”
minor“Sometimes staff issues are openly discussed throughout the service by the manager and staff... The manager gets grumpy if you're off sick.”
incident learning
1 finding
critical“There was limited evidence of learning from accidents or incidents and what, if any action was taken when things went wrong.”
infection control
1 finding
critical“We found all areas of the service to be dusty which showed the cleaning schedules were not effective. We saw there were shortfalls throughout the service relating to infection control.”
care planning
1 finding
moderate“We found one person needed their care file updating as they were now unable to get out of bed. This was discussed with the registered manager and the care records were reviewed immediately.”
consent capacity
1 finding
minor“Capacity assessments, and best interest decisions were recorded on a document that was not headed with the registered providers name... this could be misleading.”
supervision appraisal
1 finding
moderate“We noted that staff appraisals had not been completed since 2012.”
other
1 finding
moderate“Some areas within the service were being used as storage space but were still accessible to people who used the service presenting a risk to their safety.”
person centred care
1 finding
minor“The service did not have a planned activities programme and planned activities were not displayed so that people who used the service knew what was happening.”