critical“two incidents where people had fallen whilst care was being delivered but the registered manager was not aware these incidents met the criteria for allegations of neglect and failed to report them”
care planning
1 finding
critical“where people had a diagnosis of dementia, this was not thoroughly factored into assessments. For example, type of dementia, what stage of the disease people were at”
consent capacity
1 finding
critical“The registered manager did not work in accordance with the MCA and its Code of Practice...no documentary evidence to show whether people or those who represented them had given consent”
governance
1 finding
critical“Governance systems were ineffective and care records relating to the management of the service were not always fully completed, accurate and fit for purpose.”
complaints handling
1 finding
critical“The provider did not have effective systems to make sure all complaints were documented, investigated, and ensured people were always provided with the outcomes.”
incident learning
1 finding
moderate“There were no records of audits undertaken of accidents and incidents and analysis to determine if there were any emerging patterns to learn and make further improvements.”
staff training
1 finding
moderate“Staff were not appropriately inducted and their competency to perform certain tasks whilst undergoing training, was not assessed.”
supervision appraisal
1 finding
moderate“The service had a supervision policy, but current practice showed this was not being followed...No formal records of yearly appraisals records were cited.”
record keeping
1 finding
moderate“Care records relating to care and support were not always legible, kept up-to-date and contemporaneous.”
end of life care
1 finding
minor“care records viewed did not always reflect people's wishes and preferences relating to end of life. Instead care records...would only indicate if people had do not resuscitate orders”
person centred care
1 finding
minor“the service missed the opportunity to add staff's knowledge about people's life stories, to peoples' plans of care and grab sheets.”
leadership
1 finding
critical“The registered manager had lost managerial oversight of the service and failed to follow policies and procedures which, if followed, would have helped them to be compliant”