critical“They had not followed the provider's policy or national guidance on setting up and using CCTV... not completed an assessment of the purpose, necessity and risks of using such equipment.”
critical“The registered manager had not effectively operated their governance systems so as to address all of the issues we found the last time we inspected or to identify and address the issues we found at this inspection.”
critical“the provider did not always operate effective systems for monitoring and improving the quality of the service.”
care planning
3 findings
minor“There was little evidence the service used person-centred approaches and tools to plan with some people with significant disabilities, and those important to them, to understand their goals and aspirations.”
critical
“Risk management plans did not effectively assess and manage risks to the person and staff presented by the person's mobility and swallowing needs.”
critical“the person's care plan did not always reflect the care they received... This was a breach of Regulation 9”
consent capacity
2 findings
critical“There was not a clear assessment of the person's capacity to make that decision or an appropriate record of a best interests decision being taken in line with required guidance.”
critical“Records of seeking the person's consent... had been signed by a relative... there was no record the relative had the legal authority to consent to these things on behalf of the person.”
record keeping
2 findings
minor“Recording of hot water temperatures in one of the services noted temperatures over 43°C at times, indicating potential for an increased risk of injury to people.”
critical“Records of daily care from the four weeks prior to our visit documented that the person was visited by a care worker the registered manager stated was not in the country over that time.”
staffing levels
1 finding
critical“The registered manager had not obtained a reference from a worker's most recent care and support employer... could not demonstrate they had sufficiently established a reasonable account of 2 other workers' prior employment histories.”
staff competency
1 finding
critical“the provider had not always followed safe recruitment processes to help make sure they only employed suitable staff.”
staff training
1 finding
moderate“the registered manager could not demonstrate that the staff member was working to complete training to become competent in their role in line with the Care Certificate.”
safeguarding
1 finding
moderate“the provider had not completed a risk assessment of the person's home environment to make sure it was safe for staff to provide the care being asked of them.”