critical“The provider didn't always recognise when a mental capacity assessment and potential best interest decisions were needed. This meant one person was not experiencing the least restrictive option at meal times”
governance
1 finding
critical“The provider told us audits of the service had not been maintained. This meant that although the provider received daily information about care in people's homes, there wasn't sufficient oversight”
supervision appraisal
1 finding
moderate“Records suggested one staff member had not been supervised since December 2020, two since February 2021, and three since March 2021.”
record keeping
1 finding
moderate“The provider was unable to show us written evidence of disciplinary actions they had taken when required, telling us they hadn't kept a written record.”
leadership
1 finding
moderate“There hadn't been a registered manager at the service since 25 August 2021. However, a new registered manager had been appointed and a start date planned.”
communication with families
1 finding
moderate“The local authority told us three packages of care were returned with no notice and, from their perspective, no attempt to resolve the issue that caused the handback.”
staffing levels
1 finding
minor“The timing of visits had also been affected by the service being short staffed. The provider told us this might have an impact on people's routine and choice about timing of visits.”