critical“The assurance processes for ensuring the proper and safe use of medicines was not effective as it had not identified and corrected the inappropriate recording of medicines support.”
moderate“We did not see evidence that the registered manager had enabled people to give their views independently, supported by an advocate or family member or evidence of other checks and audits”
critical“quality assurance systems had not identified and addressed that some people's care plans had not been updated...This demonstrated a breach of Regulation 17”
critical“The provider had systems to monitor the quality of the service...but these were not always effective.”
record keeping
4 findings
moderate
“One person's MARs for the eight weeks prior to our inspection had only been ticked instead of initialled by visiting care staff.”
moderate“these checks did not pick up some issues the provider needed to address. This included the need to improve the recording of the support care workers gave people with their prescribed medicines”
minor“staff did not clearly record their weekly support for person to access their local community”
moderate“Two of the three records we saw were not person-centred, they referred to people as 'the client' rather than their preferred name.”
care planning
3 findings
critical“Risk management plans did not always clearly identify risks to people's safety and wellbeing or provide care staff with the information to enable them to reasonably mitigate these risks.”
moderate“some care plans had not been reviewed to ensure they were up to date and reflected people's care...one person's care plans had not been updated for over a year”
minor“Other care plans consisted only of a list of tasks for care workers to complete on each visit and did not provide care workers with information about how the person preferred to be supported.”
consent capacity
2 findings
minor“one person's care plan did not clearly record if they had agreed to their care arrangements or a relative had agreed on their behalf”
critical“We did not see a mental capacity assessment to confirm the person did not have the capacity to make specific decisions about their care, nor did we see evidence of a Lasting Power of Attorney.”
medication management
2 findings
critical“Care plans and medicines administration records (MARs) did not provide a clear record of the medicines that people required or received and the support they needed with their medicines.”
minor“in all three records care workers recorded they 'gave' people their medicines”
end of life care
2 findings
minor“Care plans did not contain any information around people's wishes, views and thoughts about end of life care as this had not been considered as part of the care planning process.”
minor“some plans did not record the provider had discussed end of life care preferences with a person”
staff training
1 finding
moderate“Some staff were over-due training sessions...including training in communication and record keeping, confidentiality, first aid and infection control.”
staff competency
1 finding
moderate“Staff we spoke with could not give us accurate information about understanding and working within the framework of the MCA.”
person centred care
1 finding
critical“People did not have up to date care plans that were personalised to fully reflect their physical, mental, emotional and social needs.”
communication with families
1 finding
moderate“some did not always identify people's communication or sensory impairment needs...one person used a hearing aid, but this was not recorded in their care plan”
staffing levels
1 finding
critical“Three of the five staff files we checked included only one reference.”
safeguarding
1 finding
critical“Another record included a photocopy of a DBS certificate from another care agency...the provider had failed to identify and follow this up with the care worker.”