critical“There were not always appropriate risk assessments and care plans to guide staff on how to provide care to people in a safe way and meet their needs.”
safeguarding
1 finding
critical“The provider had failed to recognise when risk assessments were needed to ensure people's care was safe and this put people at risk of harm.”
consent capacity
1 finding
critical“The provider did not demonstrate a good understanding of when a Mental Capacity Act assessment should be carried out.”
governance
1 finding
critical“Their quality assurance system was insufficient and did not include checks on records such as care plans to identify potential omissions or required changes.”
record keeping
1 finding
moderate“One care plan stated a person's intake was poor and fluid needed to be recorded and encouraged. However, it did not state what the fluid target should be.”
staff competency
1 finding
moderate“Only one of the four staff we spoke with could tell us about risks to people they cared for and how these were managed and mitigated.”
end of life care
1 finding
moderate“Whilst staff had undertaken training in supporting people coming to the end of their life, there was no end of life care planning in place.”
leadership
1 finding
moderate“Some staff raised concerns about the negative working environment and how they were treated by the provider and senior managers.”
person centred care
1 finding
minor“Care plans were brief, and task focused. We recommend that these could be developed further to include more about people's preferences.”
incident learning
1 finding
moderate“There were insufficient governance systems in place which meant the service had not been able to independently identify the shortfalls we found.”