minor“Staff had not received any training in end of life care. They told us discussing these subjects can be very difficult for people and staff.”
minor“Policies and procedures relating to end of life care were not in place.”
cultural competency
1 finding
minor“we saw only people's religion had been recorded. People's age, disability, ethnicity, sexual orientation and gender were part of who they were.”
safeguarding
1 finding
critical“there had been one allegation of abuse, the registered manager had carried out an investigation, but had not raised this concern with the appropriate body.”
governance
1 finding
critical“Record-keeping was not holistic and comprehensive, and there was a lack of robust systems and processes to assure the quality of service people received. This was a breach of regulation 17.”
medication management
1 finding
moderate“Where people were prescribed, as required medicine, protocols were not in place regarding their use. Staff had been trained in medicines, but competency assessments were not carried out.”
care planning
1 finding
moderate“Care plans lacked information explaining how they supported people in relation to personal care. Care plans did not contain a copy of peoples' financial profiles.”
infection control
1 finding
moderate“Staff had not been given infection control training. Care plans did not contain information about how to reduce the risk of infection.”
staff training
1 finding
moderate“Additional training needed to be provided relating to infection control, diabetes, epilepsy, manual handling, and oral healthcare, equality and diversity.”
consent capacity
1 finding
moderate“Staff was not routinely trained in the MCA and DoLS. The registered manager and staff needed to develop their understanding of the requirements of the Mental Capacity Act 2005.”
record keeping
1 finding
moderate“The registered manager told us they carried out audits but had not recorded what key areas of the service they had audited. 'I dip in and out of the service, but I don't record the checks I do.'”
incident learning
1 finding
moderate“The registered manager needed to introduce a system to enable them to monitor when accidents and incidents had occurred. There was limited use of systems to record when safety concerns had been discussed.”
complaints handling
1 finding
minor“The complaints policy was available but needed to be developed to meet current best practice guidelines. The policy did not provide information about how people could raise or escalate any complaints.”
communication with families
1 finding
minor“People were not asked for their views, and if they were, they weren't recorded, so this information couldn't be used to ensure that people received a service they were satisfied with.”
person centred care
1 finding
minor“People's care plans did not consider how information and communication needs could be met. People's communication needs were not identified, recorded, and highlighted in care plans.”