moderate“We also found information which had been copied and pasted from one person's care plan to another person's. This led to there being contradictory information about the person's personal care routine.”
governance
1 finding
critical“The nominated individual told us they had not completed any audits; care plans, staff files or care notes had not been audited to ensure the quality of people's care.”
record keeping
1 finding
critical“Risks to people were not always recorded and information provided to staff did not always mitigate risks.”
staff training
1 finding
moderate“At the time of our inspection, the provider had not kept their systems up to date to effectively monitor staff training.”
staff competency
1 finding
moderate“There had been no observations of staff at the time of the inspection. This was not best practice.”
infection control
1 finding
moderate“They told us they had no systems in place to request or record staff testing, so were unable to demonstrate best practice in this area.”
end of life care
1 finding
minor“Care plans did not contain information about people's end of life wishes.”
person centred care
1 finding
moderate“Care plans were not always person centred... one person's care plan stated they had a lifelong health condition that affected their movement and co-ordination. This condition was not named until halfway through a section.”
communication with families
1 finding
minor“The service recorded people had varied communication needs but these were not sufficiently detailed. Care plans used terms such as '[Person] can communicate through expressions and gestures' but did not provide further information.”
leadership
1 finding
moderate“At the time of our inspection there was not a registered manager in post.”