critical“Mental capacity assessments were not decision specific...the outcome opposed the findings of the assessment of capacity.”
critical“People who required assistance with medicines due to either lacking or fluctuating capacity did not have decision specific mental capacity assessments or best interest decisions.”
care planning
2 findings
moderate“Care plans did not include specific care plans around people's health conditions. For example one person had a diagnosis of Parkinson's disease, but there was no care plan around this.”
critical“People's care records did not contain health care plans. One person was diagnosed with Parkinson's and another person had a diagnosed heart issue. There were no care plans around this.”
incident learning
2 findings
minor“The provider had not implemented a monthly analysis of accidents and incidents.”
critical“Staff did not respond appropriately to somebody who had suffered a stroke. 'They're still pending stroke training apart from one person. There's no reason why it's taken so long.'”
safeguarding
1 finding
critical“Safeguarding concerns had been reported to the local authority by a relative regarding possible neglect from the service. The nominated individual had not fulfilled their regulatory responsibility by notifying us.”
medication management
1 finding
critical“MAR charts stated that medicine was to be given 'twice a day'. There were no protocols in place for 'as and when' medicine (PRN) meaning that staff would not be aware of the safe correct dosage.”
staff training
1 finding
critical“No staff members had completed dementia awareness, stroke awareness, personal care, or risk assessment mandatory training.”
governance
1 finding
critical“No audits had been completed. The nominated individual told us, 'I haven't started doing any audits. At the moment I'm doing more care than I should be.'”
record keeping
1 finding
critical“Risks to people were not always appropriately recorded and managed. One person was at risk of pressure sores. However, there was no risk assessment around this.”
supervision appraisal
1 finding
moderate“Staff were not formerly supervised in their role. 'They haven't been very often, but we've done quite a number. [The registered manager] would go in and write that she had been there... They haven't been recorded otherwise.'”
staff competency
1 finding
moderate“Regular competency checks were not being completed which would have identified the shortfalls identified earlier in this section.”
complaints handling
1 finding
moderate“The nominated individual told us that they had received no complaints. There were no complaints recorded. However, people and staff told us about complaints that had not been recorded.”
person centred care
1 finding
moderate“People and relatives told us they were not involved in decisions around their care. Other people's care plans did not contain any personalised information at all.”
leadership
1 finding
critical“It was unclear when the registered manager would be returning to the service, and the nominated individual had not made us aware of notifiable incidents in line with their regulatory requirement.”
end of life care
1 finding
minor“People's end of life wishes had not been discussed or recorded. 'We haven't really approached end of life care plans. There was no reason to as such.'”
infection control
1 finding
minor“Infection control practices were not checked by the nominated individual to ensure that they were safe. Spot checks had not been recorded.”