critical“Risk management plans were not in place to ensure that there was up to date guidance for staff on what to do if people become ill.”
staff competency
1 finding
critical“The provider had failed to ensure that they had a safe and robust recruitment process in place... not always ensured they had gathered enough information about staff prior to employing them.”
incident learning
1 finding
moderate“Accidents and incidents were logged, however the provider failed to carry out any analysis and disseminate any learning to staff on how to minimise these in the future.”
governance
1 finding
critical“The provider had failed to carry out regular audits to identify issues. For example, there were no care plan audits and staff files to identify shortfalls and drive improvements.”
record keeping
1 finding
moderate“Care records were not regularly reviewed or updated if someone's needs changed. For example, if people's care needs had changed following a stay in hospital.”
communication with families
1 finding
moderate“People's communication needs had not been assessed. There were no individual communication plans detailing people's preferred method of communication.”
consent capacity
1 finding
moderate“Staff had not completed Mental Capacity training to help them understand the principles of the MCA, and so, they could understand the importance of gaining people's consent.”
end of life care
1 finding
minor“Care records did not contain advance decisions about people's choices about the end of their life. The registered manager told us that they had explored this with people where appropriate, but not documented this.”