critical“This was a breach of Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
record keeping
1 finding
moderate“Information had not been recorded efficiently, for example, mental capacity and risk not always recorded.”
care planning
1 finding
moderate“Care plans were not personalised or written to include all choices, needs and preferences that people may require. They were task orientated.”
consent capacity
1 finding
critical
“Staff were not following the principles of the MCA. One person's initial assessment stated they lacked capacity, however there was no capacity assessment completed.”
incident learning
1 finding
moderate“There was no process to analyse accidents and incidents to monitor themes and trends to reduce reoccurrence.”
safeguarding
1 finding
moderate“No systems had been developed to monitor and manage safeguarding concerns to help protect people from harm.”
staff training
1 finding
moderate“The provider had not supplied any training at the time of the inspection. The registered manager told us they were in the process of arranging training.”
supervision appraisal
1 finding
minor“The provider undertook spot checks and observation on staff practice, but did not always record this.”
leadership
1 finding
moderate“The registered manager was not always in the office ensuring good governance was in place. They did not have a good oversight of the service.”
communication with families
1 finding
minor“Standard information was not available in different format for people to access and understand, for example, large print.”