minor“There was an end of life procedure based on the 'Six Steps' approach to care. This needed to be embedded more fully into care planning to ensure that people had adequate time to consider and plan.”
minor“There was no information in any care plans about people's end of life wishes. This meant that staff would have been unable to identify how people wished to be cared for.”
medication management
1 finding
critical“Medication administration charts were not used and it was not always clear that people had received their medicines as prescribed.”
staff training
1 finding
critical
“None had completed the Mental Capacity Act training, none had completed health and safety training and none had completed dementia care training.”
supervision appraisal
1 finding
moderate“Two staff members had not had a supervision or appraisal since March 2016 and another had not had any since February 2017.”
consent capacity
1 finding
critical“People with mental health conditions known to affect their capacity had not been assessed for their ability to consent to their care and treatment.”
governance
1 finding
critical“There were no documented audits undertaken at the service. This meant there was no regular audit of medicines, training, accidents and incidents, or care plans.”
incident learning
1 finding
moderate“There was no written evidence about what action had been taken in response to the incidents but the registered manager told us they had been investigated.”
safeguarding
1 finding
critical“We had not received statutory notifications in relation to safeguarding incidents including allegations of abuse.”
care planning
1 finding
moderate“Some people had detailed and personalised care plans in place but others were more basic and were largely a list of tasks.”
missed or late visits
1 finding
minor“They're supposed to come at 8:15 but sometimes they don't come until 9:30. I've had enough by then, I want to go to bed and I'm waiting and waiting.”