critical“Risk assessments and mitigation plans were not always detailed or personalised enough to help reduce the risk of avoidable harm to people.”
critical“one person's falls care plan was an example template that had not been changed to reflect the persons' needs and the action taken. This included the wrong name”
consent capacity
2 findings
critical“the provider did not complete best interest decisions for people who did not have the mental capacity to consent to their care, and that relatives had signed consent forms without the legal authority to do so.”
moderate“There was no evidence in the training records care workers had completed training around the MCA.”
governance
1 finding
critical“systems in place to monitor service delivery were not always effective, as they did not always identify the quality of the information input or the areas requiring improvement we identified during the inspection.”
person centred care
1 finding
moderate“Care plans did not include details of people's background history and preferences, or people's cultural and religious needs.”
cultural competency
1 finding
moderate“individual needs such as people's religion and personal history were not recorded in the care plan. This meant care workers did not have guidance to help ensure people received care according to their wishes”
communication with families
1 finding
moderate“Care plans did not have a specific section for information about people's communication needs, for example the language they spoke of if they needed assistive aids such as glasses or a hearing aid.”
end of life care
1 finding
minor“People's end of life care wishes were not part of the care plan which meant care workers were not provided with guidance on how the person wanted to be supported at that time.”
record keeping
1 finding
minor“Safe recruitment practices were followed but not always recorded correctly, for example gaps in employment history.”
staff competency
1 finding
moderate“there were instances when they felt some care workers lacked the necessary skill to provide the required level of care to people.”