critical“Recruitment information was not obtained in accordance with the providers policies and procedures to demonstrate staff were of good character.”
moderate“The registered manager was not able to provide evidence of staff competency checks to assure themselves staff provided safe, quality care in line with their expectations.”
staff training
2 findings
critical“There was no clear evidence that staff had completed regular training to update their skills and knowledge to enable them carry out their roles effectively.”
moderate“At the time of our inspection there was no training matrix in place showing completed training for staff...this did not provide a clear overview of training such as when it was completed and when it expired.”
care planning
2 findings
critical“Potential risks associated with people's needs were not always identified and assessed to ensure there was clear guidance to staff on how to respond.”
critical“One person's care record stated they needed 'help to have a wash and personal care' but there was no further information to inform staff what was required and how to complete this task safely.”
medication management
2 findings
moderate“There were no body charts completed to show where the cream should be applied. The medicine administration record also did not provide instructions for staff.”
critical“Staff and relatives confirmed creams were applied to people's skin. There were no body maps completed...or medicine charts completed...to show when staff had applied creams.”
governance
2 findings
critical“Audits systems continued not to be fully effective in identifying areas needing improvement to ensure the quality and safety of the service was maintained.”
critical“The provider failed to operate systems or processes to assess, monitor and improve the quality and safety of the services provided. Accurate, complete and contemporaneous records...were not maintained.”
record keeping
2 findings
moderate“Care records and risk assessments were either insufficiently detailed or not in place which meant staff did not have the information they needed.”
critical“Records had not been sufficiently maintained to enable the provider to review records and identify when things had gone wrong.”
incident learning
2 findings
moderate“Opportunities for continuous learning and improving care had been missed because the provider did not have effective systems and processes to identify where improvements may be needed.”
moderate“A monitoring activity completed by CQC in June 2021 had identified improvements were needed including records management...we saw these improvements had not been acted upon.”
staffing levels
1 finding
critical“DBS checks had not been requested by the provider in line with their recruitment policy.”
safeguarding
1 finding
critical“the safeguarding incident had not been escalated to all agencies as required. There was no safeguarding log showing any safeguarding incidents that had occurred.”
leadership
1 finding
critical“The lack of managerial oversight meant information was lacking in relation to staff recruitment and training to ensure staff were safe and suitable to provide care to people.”
person centred care
1 finding
moderate“Care records were either insufficiently detailed or were not in place which meant staff did not have the information they needed to provide safe, person-centred care.”
end of life care
1 finding
minor“One person's care plan stated they had a 'ReSPECT' in place but this was not available within the care records shared. This was important to help ensure the persons wishes were followed.”