critical“Two incidents which should have been safeguarded had not been recognised by the management. No alerts to the local authority safeguarding team or CQC had been made in line with legislation.”
medication management
1 finding
critical“Medicines records did not meet best practice requirements as they did not contain details of individual medicines administered.”
governance
1 finding
critical“Audits were inconsistently completed or did not exist. For example, audits for accidents and incidents contained months that were blank.”
care planning
1 finding
critical“People's care plans contained no risk assessments meaning staff could provide inconsistent and unsafe care.”
incident learning
1 finding
moderate“A second group of electronic incidents were shared by one of the directors. The registered manager was unaware of this second group, so they had not been reviewed.”
staff training
1 finding
moderate“6 out of 13 staff had not received training in safeguarding and some had only read the company policy as their training.”
record keeping
1 finding
moderate“The provider had recently introduced several digital systems. This had led to gaps in people's care records including a lack of assessing risks.”
infection control
1 finding
minor“No individual COVID-19 risk assessments had been completed during the pandemic unless the person was COVID-19 positive. This was not in line with government guidance.”
supervision appraisal
1 finding
minor“The systems to listen to staffs' views and those of people who use the service had not been utilised for over a year.”
leadership
1 finding
moderate“The directors and registered manager lacked knowledge on current legislations, guidance and standards.”