critical“one person who had recently suffered two separate episodes of fainting did not have their risk assessments and care plan updated to reflect any change in their care needs.”
moderate“Risks to people were not always identified. Risk assessments were not always carried out for medicines, falls and moving and handling.”
governance
2 findings
critical“The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service.”
moderate“The provider was not fully aware of their responsibilities under current health and social care legislation.”
record keeping
2 findings
moderate“employment histories were not always completed in full. The provider had not established reasons for gaps in employment”
moderate“their moving and handling risk assessment did not identify the potential risks of using these mobility aids and there was no guidance in place for staff”
incident learning
1 finding
critical“Accidents and incidents were not always recorded and followed up and learning was not disseminated to staff.”
staff competency
1 finding
critical“Recruitment procedures had not been carried out to ensure that staff were of good character or have the skills and experience necessary to provide care.”
end of life care
1 finding
moderate“People's care plans did not have people's end of life wishes and preferences documented.”
safeguarding
1 finding
critical“The provider had failed to notify the local safeguarding authorities and CQC about these incidents.”
medication management
1 finding
moderate“Risk assessments did not identify what staff should do if people refused their medicines, there was no guidance in place for staff on what they should do if this happened.”