moderate“Information gathered from audits, 'spot checks' and accident/incident reporting was not collated so that areas for improvement and development were clearly identified.”
moderate“governance systems continued to require improvement, as the provider and registered manager had not identified the areas of improvement we found during our inspection visit.”
minor“The provider had failed to respond to CQC's requests for information in the form of the provider information return.”
consent capacity
2 findings
critical“The policies and systems in the service did not support the assessment of people's mental capacity to determine how and when best interests' decisions were made.”
moderate
“we found some consent forms had been signed by family members rather than the person receiving care, which did not demonstrate people had been involved in decisions relating to their own care.”
staff training
1 finding
moderate“There was an induction programme in place and all new staff were required to complete the Care Certificate; however, we found that this was not consistently delivered.”
safeguarding
1 finding
critical“The provider needed to ensure that any issues raised with the local authority around safeguarding also needed to be notified to the Care Quality Commission(CQC).”
complaints handling
1 finding
minor“The procedure was not followed consistently which meant that people were not always made aware of where else they could raise their complaint if they remained unhappy.”
incident learning
1 finding
moderate“The provider and registered manager needed to ensure that when complaints were made consideration was given as to whether any issues raised linked to other procedures such as safeguarding.”
care planning
1 finding
moderate“we found people who had a catheter did not have risk management plans in place to instruct staff on spotting the signs of catheter related risks.”
staff competency
1 finding
moderate“staff did not always have a reference from their last known employer, in line with the provider's own recruitment policy, before commencing work at the service.”