critical“The registered manager discussed an ongoing safeguarding issue which required reporting to the relevant authorities. However, this was not done until after day 1 of the inspection.”
governance
1 finding
critical“Not all statutory notifications in relation to some events had been submitted. The provider had also failed to submit their annual Provider Information Return since 2021.”
care planning
1 finding
moderate“Care records contained some evidence of individual risk assessments. However, not all people's individual risks had been assessed.”
consent capacity
1 finding
moderate“A capacity assessment for 1 person where it was required was not completed until after day 1 of the inspection.”
incident learning
1 finding
minor“There was evidence of completed accident and incident records. However, the records would benefit from more detail to reduce any future risk and support monitoring.”
complaints handling
1 finding
minor“The complaints procedure in the service user guide was not always detailed, in line with the provider's policy.”
leadership
1 finding
moderate“Some professionals told us that engagement with the management team was inconsistent and they did not always consistently acknowledge requests for information.”