moderate“there were no details in the records of the medicines and how often these needed to be prompted...no medicine records to give staff guidance on how much of their medicine was needed”
consent capacity
1 finding
critical“there were no mental capacity assessments in place for people...we could not be assured that the provider was working in line with the principles of the MCA 2005”
staff training
1 finding
critical“not all staff had received training in safeguarding and the MCA. Staff we spoke with had varying knowledge in safeguarding and poor knowledge of the MCA”
staff competency
1 finding
moderate“there were no systems in place to ensure that staff had understood the training provided...the registered manager and provider were unaware that staff had varying knowledge”
governance
1 finding
critical“there were no specific audits in place to check that people were receiving the care required...no medication audits, audits on care files or other areas of care”
record keeping
1 finding
moderate“records did not always contain an accurate reflection and reviews of people's care had not been recorded where changes had been made”
supervision appraisal
1 finding
moderate“staff had not always received a supervision...other staff had not yet received a supervision to discuss their role and any development needs”
cultural competency
1 finding
minor“the assessment form did not detail specific information about people's diverse needs such as cultural background, religion or their sexuality”
care planning
1 finding
moderate“people's risk assessments did not always contain sufficient details and there was a potential risk that new staff would not have the information required to support people safely”
end of life care
1 finding
minor“conversations with people about end of life care were not routinely undertaken. They were only in place when people were nearing end of life.”
person centred care
1 finding
minor“people were not asked about their sexuality, following our feedback, the provider had plans to ensure this would be implemented and recorded during people's admission stage.”