critical“The provider had failed to ensure that risks relating to infection control and the transmission of COVID 19 were being effectively managed.”
care planning
1 finding
critical“This information did not form part of this person's care plan and there was no risk assessment in place to guide staff as to any actions they should take to keep this person, themselves and others safe.”
governance
1 finding
critical“The provider did not have effective systems in place to assess, monitor and improve the safety and quality of the service.”
incident learning
1 finding
moderate“Systems were not fully embedded or robust enough to demonstrate accidents and incidents were effectively monitored, reviewed or used as a learning opportunity.”
other
1 finding
critical“The provider had failed to ensure that recruitment procedures are established and operated effectively.”
consent capacity
1 finding
moderate“the management team did not have a good understanding of the Mental Capacity Act and DoLS process within community settings. This lack of understanding had led to one person having various restrictions placed upon them without a legal basis”
staff training
1 finding
moderate“we found staff had not completed an induction in line with Care Certificate Standards.”
record keeping
1 finding
minor“The language used within one person's daily notes / incident records did not always demonstrate a person-centred approach and was not in keeping with best practice guidance.”
leadership
1 finding
moderate“service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”