critical“Care plans still contained none of the required equality and diversity information related to people's personal history, lifestyle choices, cultural, religious, emotional, spiritual and sexuality needs.”
minor“some elements which would enable staff to provide more person-centred care were not recorded. These included areas such as people's history, personal information about them and their likes and preferences.”
person centred care
2 findings
moderate“Support plans did not always use respectful person-centred language. For example, support plans did not refer to people by their preferred name but used the impersonal term 'the client.'”
minor“People's diverse emotional and spiritual needs were not always recorded in care plans. People's religious, cultural and lifestyle choices were not noted.”
governance
2 findings
critical“The registered manager had failed to identify and address breaches of regulation in relation to staffing, the need for consent and person-centred care planning.”
moderate“missed or late calls were therefore, reported to the service... the care co-ordinator told us they called care staff every day to check they had completed their calls. However, this was not recorded.”
record keeping
2 findings
moderate“People's daily notes did not always record the times of their visits... all requested staff rota information had not been provided.”
moderate“three of the four reviewed did not contain enough detail to show a complete history of their employment since leaving full time education”
staffing levels
1 finding
critical“The provider was unable to demonstrate that enough suitably competent and experienced staff were deployed to make sure people's care and treatment needs were met safely.”
consent capacity
1 finding
critical“Consent to care and treatment was not always sought or recorded in accordance with the MCA. This was a breach of Regulation 11 (Need for Consent).”
missed or late visits
1 finding
moderate“One person told us, 'They're never on time and they do not let me know if they are running late... I will often cancel as I know that if I have to wait for them I won't make my appointment.'”
incident learning
1 finding
minor“it was clear actions were taken to minimise the risk of recurrence, the actions taken were not always recorded”
medication management
1 finding
minor“the responsibility the service took regarding people's medicines was not always clear”