critical“The lack of robust governance system and processes as well as management oversight was a breach of Regulation 17”
consent capacity
1 finding
critical“The failure to follow the principles of the Mental Capacity Act 2005 was a breach of Regulation 11”
staff competency
1 finding
critical“registered manager was not always meeting the requirements of Schedule 3... breach of Regulation 19”
medication management
1 finding
moderate
“we found gaps in people's MARs and a lack of double signatures on handwritten prescription entries, meaning the audits were not being robustly carried out”
record keeping
1 finding
moderate“Some care plans we requested could not be found on the system and two people's care plans had been stored under an incorrect name.”
leadership
1 finding
moderate“staff shared with us a message sent out by the service with a list of possible questions we may ask them, together with the responses they should give”
supervision appraisal
1 finding
moderate“staff told us they did not feel supported or valued. They had raised some concerns during supervision with the registered manager.”
staffing levels
1 finding
moderate“two live-in care staff worked 12-hour shifts without another carer arriving to give them a break”