moderate“There had been no registered manager in post since January 2020. We found registered manager applications to CQC had been made by managers, but these had been unsuccessful.”
moderate“The provider's recruitment policy did not reflect their recruitment practices using the Home Office Sponsorship Scheme and any associated risks when recruiting from abroad.”
critical“The provider's monitoring processes and records were not effective in demonstrating how they monitored the service to enable them to drive improvements.”
moderate“systems to monitor the quality of care being delivered such as medicines audits had not always been completed”
record keeping
3 findings
moderate
“the provider had not considered whether DBS checks would be required to support their vetting and recruitment process for staff who were being recruited from abroad”
critical“the provider had not maintained accurate, complete and contemporaneous records for each person. This was a breach of regulation 17”
moderate“Records to demonstrate the safe recruitment and development of staff had not always been maintained.”
medication management
2 findings
minor“staff would benefit from body maps to help direct and identify areas which require cream application.”
critical“people were at risks of not receiving their medicines and creams as comprehensive medicines management care plans were not in place”
care planning
2 findings
critical“the provider had not ensured their own record of the assessment of people's needs and support were accurate and complete.”
moderate“risk management care plans for some people needed more information to describe the agreed management and monitoring of people's risks and medical conditions”
leadership
2 findings
moderate“There was no registered manager in post at the time of the inspection...their management and governance systems had been compromised.”
moderate“effective handover between the managers had not been carried out which meant that the current manager did not have full access to some of the providers operational systems”
incident learning
1 finding
minor“we found one incident which should have been notified to CQC. The provider explained this had been an oversight.”
supervision appraisal
1 finding
moderate“the manager was unable to show us the records they had kept relating to their observations and supervisions of staff, medicines record checks and feedback from people.”
communication with families
1 finding
moderate“Two relatives stated they had requested but hadn't been given access to people's care plans or staff daily records to help them understand people's welfare.”
staffing levels
1 finding
critical“limited evidence to show that the provider had explored the gaps in staff's recruitment documents and checks to determine that they were of good character”
consent capacity
1 finding
moderate“assessment of people's mental capacity and the outcome was not routinely recorded to help direct staff in delivering care in people's best interest”
complaints handling
1 finding
minor“one relative raised a concern with the manager which was investigated and discussed with the relative, although this had not been recorded”