critical“People's care records and risk assessments were not comprehensive, did not always reflect people's care needs and were not always person-centred.”
medication management
1 finding
critical“Medicine records were inconsistently completed... Some care records were contradictory. For example, for one person it stated they could 'self-medicate', another part stated they needed 'prompting and supervising'.”
governance
1 finding
critical“The provider did not have effective governance systems in place to assess, monitor and improve the quality and safety of people's care. This was a breach of regulation 17(1).”
incident learning
1 finding
moderate“Incidents were recorded; however, there was no review and analysis conducted by the manager or the provider to ensure the on-going risks to people's safety had been addressed.”
consent capacity
1 finding
moderate“People's capacity and assessments around this were poorly documented. It was not clear from people's plan what level of capacity they had and what decisions they could make.”
person centred care
1 finding
moderate“Care plans followed a standardised format with little evidence of person-centred care planning... daily routines recorded for staff to follow each day lacked specific details of people's preferences.”
cultural competency
1 finding
moderate“Only 8 of 28 care staff had completed equality and diversity training. This could place people at risk of discrimination.”
communication with families
1 finding
moderate“A care plan stated a person did not speak English... however, no communication care plan was in place. This meant the person may receive inconsistent support.”
complaints handling
1 finding
minor“The provider's complaints policy lacked specific details required to inform people how their complaint would be handled and who by. No timescale was provided.”
leadership
1 finding
moderate“The current manager was the third manager in post in the last 12 months. This has contributed to inconsistent and ineffective quality assurance processes.”
staff training
1 finding
minor“Additional training... had not yet been completed by all. The provider did not have the processes in place to monitor and address this with staff.”
record keeping
1 finding
moderate“Records were often not accurate or up to date. Where accidents or incidents had occurred there was little investigation, analysis, or review to try to identify the cause.”