25 February 2019
During a routine inspection
People’s experience of using this service: Risks to people’s health were not always assessed to provide staff with the necessary guidance on how to keep people safe. Medicines were not always managed safely and quality checks had not picked up on areas where improvement was needed. The provider was not ensuring that staff had the qualifications, skills and experience to provide care safely.
New staff had not completed a full programme of training. The registered manager had an understanding of mental capacity, and people’s rights around making their own decisions. However, they were not correctly recording capacity assessments or best interest decisions.
Complaints were not being correctly recorded and one relative was not happy with the way their complaint was handled.
The service’s internal systems had failed to identify the issues we found on our visit. People and their relatives had not been regularly asked for feedback on the service.
Staff were kind and patient and people were involved in decisions about their care.
People received care that was personalised to them but care plans were not always up to date or accurate.
We identified four breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around safe care, fit and proper persons employed, complaints and governance. Details of action we have asked the provider to take can be found at the end of this report.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk.
Full information about CQC's regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.
Rating at last inspection: This was the service’s first inspection since becoming registered on 30 November 2017.
Why we inspected: This inspection was a scheduled inspection carried out in line with our inspection programme timescales.
Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.