critical“People's medicines were not managed safely to ensure they were not placed at risk.”
staff training
1 finding
critical“Staff had not been provided with training to provide safe care.”
safeguarding
1 finding
critical“The provider had not fully protected people from the risk of abuse and improper treatment.”
staff competency
1 finding
critical
“The staff member we spoke with was not aware of the risks to, or their care needs of, the person they supported.”
supervision appraisal
1 finding
critical“Staff did not receive regular supervision... One member of staff told us 'I've not had any supervisions since I started.'”
care planning
1 finding
critical“No risk assessments or care plans had been completed for the person who was currently using the service”
person centred care
1 finding
critical“People did not have person-centred care plans in place to help staff ensure they received personalised care.”
governance
1 finding
critical“The provider had failed to implement effective systems to assess, monitor and improve the service.”
leadership
1 finding
critical“There were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
incident learning
1 finding
critical“We were not assured incidents and accidents involving people were consistently reported, recorded and investigated to promote learning and minimise the risk of reoccurrence.”
infection control
1 finding
moderate“We were not assured staff were disposing of personal protective equipment (PPE) correctly.”
complaints handling
1 finding
critical“The provider did not have a complaints policy or systems to record or respond to complaints.”
consent capacity
1 finding
critical“The provider was not working in line with the principles of the MCA. They were unable to evidence that people's rights under the MCA were being protected.”
record keeping
1 finding
critical“Records were of poor quality and did not include a complete, accurate and contemporaneous record of care provided.”
communication with families
1 finding
moderate“Their relatives told us the provider had not involved them in care reviews, which meant they did not have appropriate opportunities to contribute towards decisions about their loved one's care.”
cultural competency
1 finding
moderate“one person did not speak English. The provider had not given key information or documents, such as care plans, to the person in their own language.”
end of life care
1 finding
minor“We saw no evidence in people's care plans that their wishes and preferences regarding their end-of-life care had been discussed with them”
other
1 finding
critical“The provider had not adhered to safe recruitment practices. This placed people at risk of being supported by unsuitable staff.”