critical“risk assessments and support plans contained some information for staff, but did not contain a sufficient level of detail about how care workers were expected to mitigate known risks.”
moderate“we did not find evidence of specific risk assessments relating to the risk of people falling in any care records we viewed.”
minor“care records did not always include exact details of what assistance people needed in relation to their nutrition.”
critical“risk assessments were either not in place or contained unclear or inconsistent information for care workers particularly in relation to people's moving and handling needs”
moderate“care records did not always contain information about people's likes and dislikes in relation to food... no information about the type of food the care worker was required to prepare”
record keeping
3 findings
critical“The provider did not always maintain an accurate and complete record in respect of each service user. Regulation 17(1)(2)(c).”
minor“we identified the policy was to request only a five-year work history when recruiting new staff. We recommend the provider review their recruitment procedure to ensure it fully meets current requirements.”
moderate“care records contained very limited personalised information about their care needs or their backgrounds”
governance
2 findings
moderate“the organisation's internal monitoring did not include a check of people's care records and therefore, the issues we found in relation to people's care records had not been identified.”
critical“provider had auditing systems in place, but these were still not consistent... MAR charts for three people... were not available. Daily notes that were available were for September”
person centred care
2 findings
moderate“most care records contained either very limited or no information about people's life history or preferences in relation to how they wanted their care to be delivered.”
critical“care records contained very limited details about people's individual needs and preferences... one person's care record did not have a list of tasks included at all”
medication management
1 finding
critical“medicine records were not always accurately completed... one person's MAR for October contained three gaps, but there was no information recorded to indicate why”
consent capacity
1 finding
critical“records were not always signed by the person using the service or their legally authorised representative... a mental capacity assessment that did not conclude whether or not the person had capacity”
supervision appraisal
1 finding
moderate“most care workers were receiving either one or two supervision sessions in 2018... some care workers had not received an appraisal in 2018”
communication with families
1 finding
minor“They don't tell me they are sending someone different, it's irritating”