critical“Systems had not been established to effectively assess, monitor and mitigate risks to the health, safety and welfare of people using the service.”
critical“We have identified a breach in relation to the governance and leadership of the service, this is about a lack of systems and quality monitoring checks completed by the registered manager and provider.”
incident learning
1 finding
moderate“There were no systems in place to respond to a person if they had a potential injury such as a bruise. This could be a potential sign of abuse or indicator a person needed some more support.”
safeguarding
1 finding
moderate
“some staff did not know they could report concerns to the local authority and to us. This is important to promote people's safety.”
care planning
1 finding
moderate“People did not always have complete risk assessments, which identified and explored all the risks which they faced. Staff did not have clear and thorough care plans to guide them about how certain risks should be managed.”
staff training
1 finding
moderate“There was no timely follow up training or recorded checks by the registered manager to see if staff had understood this training. When we asked staff to tell us about this training, staff were unable to recall what they had learnt”
staff competency
1 finding
moderate“Thorough competency checks were not being completed and recorded to check this training had been effective and people were safe.”
consent capacity
1 finding
moderate“When an individual was considered to not always have capacity, this was identified by the registered manager. But they had not documented how they had reached this conclusion and what actions should be taken”
record keeping
1 finding
moderate“Their care plan, risk assessment, and reviews did not explain this risk, what advice professionals had given, and how this need was to be managed by staff.”
leadership
1 finding
moderate“The registered manager and provider were not always clear about their role in terms of quality monitoring and knowing the regulatory requirements.”