moderate“not all of these had been recorded in people's care plans and we identified these needed improvement”
moderate“management had identified that improvements were needed for record keeping and care rotas but there was no evidence as to how this had been identified and the actions to address the problems.”
consent capacity
2 findings
minor“Whilst staff were aware which people did not have capacity to make specific decisions for themselves, mental capacity assessments were not recorded”
minor“Whilst some staff had received training on the Mental Capacity Act (2005) (MCA), the majority had not.”
supervision appraisal
2 findings
minor“the registered manager was aware these were behind schedule... 'I think I have only ever had one appraisal in four years'”
minor“the registered manager team said they were not up to date with staff appraisals.”
complaints handling
2 findings
minor“The service had a complaints policy and procedure. This did not include the up to date contact details for all the alternative organisations to contact.”
minor“one person who said they had made a complaint but had not received an outcome of findings from management.”
medication management
1 finding
moderate“10 medicine errors had been made in the last 12 months... the system in use was not safe or robust, particularly for people with a dementia related illness”
infection control
1 finding
minor“we saw two staff who had very long pointed false nails and a selection of varied rings on their fingers... both an infection control concern and an unnecessary risk of skin damage”
care planning
1 finding
moderate“this information was not always kept together which made it difficult to follow... made it difficult for staff to follow the care plan to seek guidance to ensure consistency in care”
governance
1 finding
moderate“these were not always recorded and did not identify problems which needed to be addressed...there was not a consistent approach to provide complete assurance.”