critical“One person had a bed/chair sensor in place no mental capacity or best interest decision was recorded and this was not referenced within the persons care plans or risk assessments.”
moderate“There was a lack of decision specific capacity assessments and best interest decisions balancing the benefits and burdens of each specific decision.”
record keeping
2 findings
moderate“Care intervention records were not always recorded contemporaneously...records relating to pressure area care, cream applications and pad changes for several people were incomplete.”
critical“Records relating to pressure area care, cream applications and pad changes for several people were incomplete...there were gaps in people's records.”
care planning
2 findings
moderate“Care plans lacked personal information and guidance, and some contained contradictory information...one person had no sheet on her bed or duvet...this was not reflected within the persons support plan.”
moderate“Some areas of the care plans we looked at were not sufficiently personalised and contained contradictory information.”
governance
2 findings
critical“Quality assurance processes had not identified all the areas which needed to improve...issues we found with record keeping and fire safety had not been identified by the provider.”
critical“Quality assurance processes had not identified all the areas which needed to improve...issues we found with record keeping and infection control had not been identified by the provider.”
incident learning
2 findings
moderate“Within one person care records there was evidence of three incidents, however only one of these was evidenced on an accident and incident form.”
moderate“The recording of incidents was inconsistent and there wasn't always a clear analysis of the event to ensure lessons were learnt and shared with staff.”
medication management
1 finding
critical“Medicines were not received, stored, administered, and disposed of safely...Fridge temps were not within correct limits. Some medication stock checks were incorrect on day of inspection.”
person centred care
1 finding
moderate“One person said, 'I am very happy here, but I haven't been involved in my care plan.' Their relative...also confirmed that they had not been involved.”
communication with families
1 finding
minor“Some relatives would have welcomed more communication in relation to appointments. Not everyone knew the registered manager.”
infection control
1 finding
critical“The provider was not ensuring all staff were following the latest government guidance in terms of PPE, in particular the wearing of the correct type of face masks.”
complaints handling
1 finding
moderate“The provider was not recording informal complaints such as a relative complaint about their relation wearing clothes that did not belong to them.”
end of life care
1 finding
moderate“Advanced care plans were not sufficiently detailed. We were shown a blank document for people in the last few days of life which once completed fully would provide the necessary details.”
staffing levels
1 finding
moderate“There were no agency staff profiles for temporary staff who were on duty during this inspection...the provider was unable to evidence how they had assured themselves in relation to the training and competency of these staff.”
safeguarding
1 finding
critical“A relative told us of a recent incident which had been reported to the home...the registered manager advised they had not been informed of this incident.”