moderate“We found two people's relatives had signed consent forms in relation to their care, however, there were no associated mental capacity assessments in place”
moderate“the registered manager told us that she was not aware that it was her responsibility to conduct these assessments”
critical“The provider had not obtained any documentation to indicate that the relatives had the legal authority to sign on behalf of their family members”
moderate“The care co-ordinator and care staff did not demonstrate a good understanding of the Mental Capacity Act 2005 (MCA).”
care planning
4 findings
minor
“People's care plans did not always contain enough information about their likes and dislikes in relation to food”
critical“one person who used the service required support from staff for moving and handling...there was no assessment and risk management guidance in place in relation to the use of the hoist”
minor“the care plans did not contain recent assessments and reviews carried out by external professionals such as people's social workers, psychologists and/or occupational therapists”
moderate“Care plans did not consistently reflect the personalised care described by relatives. There was limited information about people's likes, dislikes, interests and background.”
record keeping
4 findings
minor“there was limited written information about people's current circumstances or their life histories”
moderate“care staff who provided people...with an hour each morning for personal care wrote one or two sentences about the care and support they provided”
minor“the registered manager had not effectively audited records written by staff; a member of staff had used inappropriate terminology during a one-to-one supervision meeting and there was no record of any discussions”
critical“This was a breach of regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17.”
governance
2 findings
critical“The provider did not demonstrate that there was a viable quality assurance process in place in order to continuously assess and monitor how the service operated”
moderate“We found that the policy for staff development and training was out of date and we were presented with a second safeguarding policy and procedure that was inaccurate and contradicted the first one.”
staff training
2 findings
moderate“the mandatory training programme for staff was noticeably overdue and the registered manager did not have an effective system in place to monitor that staff had attended training”
moderate“Staff had limited opportunities to attend training about the needs of people using the service, for example training to update their knowledge about developments within the learning disability field.”
person centred care
2 findings
minor“the care and support plans did not reflect the standard of person-centred work that staff undertook, which was documented in other records”
minor“Risk assessments were not always person centred and focused upon people's identified needs and wishes.”
complaints handling
2 findings
minor“the provider had used an incorrect address for people and their relatives to contact the Care Quality Commission”
minor“The complaints form did not advise people about how their complaint would be managed, for example there was no information about length of time for investigation.”
incident learning
1 finding
moderate“We did not find suitable evidence that the provider was working in a manner that consistently promoted continuous development, innovation and a culture that learnt from mistakes”
supervision appraisal
1 finding
minor“bi-monthly one to one supervision from the independent consultant...these sessions were primarily concentrated on her role managing the day centre”
staffing levels
1 finding
critical“Recruitment records showed that staff had only one reference each, which was not always checked by the provider to guarantee its authenticity.”
medication management
1 finding
moderate“There was no guidance for staff in the provider's medicine policy and procedure, in the event of such an incident occurring.”