Park Cottages

CQC had not been notified of all incidents in line with regulatory requirements.

People's right were not protected in line the Mental Capacity Act because decision specific mental capacity assessment and best interest decisions were not in place and appropriate DoLS applications had not been made. Care plans were not signed by the relevant person to evidence consent to care.

Gaps in employment had not been explored and risks related to unsuitable staffing had not been assessed.

The registered provider did not ensure staff received appropriate training to support people who used the service. Staff appraisals were not completed.

Appropriate arrangements were not in place to protect people in the event of a fire. Risks to people from inadequate maintenance had not been assessed and mitigated. Effective systems were not in place to reduce the risk of scalding. Effective systems were not in place to reduce the risk of Legionella. People were not always protected from the spread of infections because an effective system of cleaning was not in place. Incidents were not always recorded and so learning from incidents could not be evidenced.

The building was not maintained and managed in safe way.

The registered provider and registered manager did not have an effective oversight of the service. The quality monitoring systems in place did not identify or address the concerns found during this inspection. The registered provider did not have an effective system in place to improve the quality and safety of the service. People who used the service and their representatives were not always asked for their views about the service. Accurate and up to date records were not always kept.