moderate“when we initially requested copies of people's records, we were not provided with the most up to date information...we were not assured staff were always accessing the most recent care records”
critical“Care plans were neither dated nor signed and the provider had not maintained a record of care plan reviews.”
moderate“Two people's assessments records had not been dated nor fully completed, lacked detail about people's needs and it was not always clear as to who had carried out the assessments.”
governance
3 findings
moderate“there was no clear system in place for monitoring feedback and spot checks”
critical
“The provider had not implemented their quality assurance and management policy. The provider's quality assurance systems did not identify the concerns we found on the inspection.”
critical“the registered person had not operated an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.”
leadership
2 findings
moderate“service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
critical“There were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
medication management
2 findings
critical“Staff had ticked medicines records to show these were given and had not initialled the records to identify who had given medicines or prompted people to take their medicines.”
critical“Staff had also not been assessed as being competent to support people with their medicines.”
care planning
2 findings
critical“People's care plans and risk assessments did not always include guidance for staff on how to effectively support people when delivering care and support.”
critical“People's care plans and risk assessments lacked detailed step by step guidance that showed any risks were understood and managed safely”
supervision appraisal
2 findings
critical“Staff supervisions had not been recorded. It was unclear how the provider was assured that staff were receiving the support they needed.”
moderate“we found only one record of one care staff having had a one to one supervision meeting with the registered manager.”
staff training
2 findings
moderate“The training matrix showed only 1 staff member had completed safeguarding training...staff had not received training in the Mental Capacity Act 2005.”
critical“The registered person did not ensure all staff were competent, skilled and had up to date training in order to carry out their role and effectively support people and keep them safe.”
consent capacity
2 findings
moderate“There was limited information and guidance about each person's capacity and ability to make particular decisions in relation to their care and support.”
moderate“The provider had not ensured staff had received training about the MCA.”
person centred care
2 findings
moderate“There was limited information about people's background and preferences...this section was not included in the other care records that were provided to us.”
critical“The registered person did not ensure people's care was always appropriate and met their needs and preferences.”
staff competency
1 finding
critical“The provider did not have safe recruitment and selection practices at the service. They had failed to follow their own policies by not obtaining all required recruitment information.”
incident learning
1 finding
moderate“There was not an effective system in place that the provider could evidence how they learned lessons when things go wrong.”
complaints handling
1 finding
moderate“this complaint had not been recorded, so the provider was not able to show their complaints procedure had been followed”
communication with families
1 finding
moderate“this person's and other people's care records contained no information about their communication and any sensory needs.”
safeguarding
1 finding
moderate“Two staff records did not show that the staff had completed safeguarding adults training.”