critical“Provider and registered manager meeting minutes of March 2023 recorded, 'Performance of company working well over past year. No action required.'”
moderate“Audits had insufficient guidance as to how they were to be completed, or the criteria to determine whether improvements were required.”
care planning
2 findings
moderate“There were multiple care records detailing people's needs. This meant staff did not have access to concise information as to people's needs.”
moderate“A person who required the use of a hoist for transfers did not have a risk assessment in place or information as to how staff were to use the equipment safely.”
record keeping
1 finding
critical“Multiple paper records stored within different files made it difficult for the registered manager to locate information throughout the inspection.”
incident learning
1 finding
critical“The previous inspection had identified shortfalls in the analysis of information and lack of planning to drive improvement. This showed the provider had not taken effective action.”
consent capacity
1 finding
moderate“A best interest decision had been completed for 2 people. Best interest decisions should only be completed where people have been assessed as not having capacity.”
complaints handling
1 finding
moderate“Records relating to concerns were stored in multiple files within the office, which made it difficult to determine the outcome of some of the concerns raised.”
staff competency
1 finding
moderate“Staff responsible for assessing people's capacity to make informed decisions had not understood the principles of the Mental Capacity Act.”