minor“some auditing systems were good and others were 'a work in progress'”
moderate“quality checks had not identified how people's lives and well-being were being affected by late and missed calls.”
moderate“Notifications were not always submitted as required...the deadline had passed and the notifications had not been submitted.”
record keeping
2 findings
minor“we saw some gaps in the records of audits that had been completed and a review of medicines records showed signature gaps that hadn't been noted during the audit.”
moderate
“Systems to ensure that staff recruitment files contained the necessary evidence needed improving as some evidence relating to DBS checks was not available.”
consent capacity
2 findings
moderate“registered manager was not able to confirm...lasting power of attorney...had not seen the required documentation.”
minor“Some staff we spoke with were not able to tell us anything about the MCA or what capacity meant.”
staff competency
2 findings
minor“one staff member believed that the manager was the person who would make decisions on behalf of people.”
minor“Some staff we spoke with were not able to tell us anything about the MCA or what capacity meant.”
complaints handling
1 finding
critical“one relative had made many complaints...written to the provider in August 2016...did not receive any written response from the provider until January 2017.”
missed or late visits
1 finding
critical“Of the 21 people we spoke with, 16 said they had late or missed calls.”
person centred care
1 finding
moderate“People were not always involved in planning their care and support...some couldn't remember if they had been involved.”
care planning
1 finding
moderate“records did not always show what legal authority they had to represent people's views.”
incident learning
1 finding
moderate“There was no formal audit of these to help identify trends...there was a risk that other trends may not be identified.”
safeguarding
1 finding
critical“One incident...about a person with a bruise on their hand. These care notes had been audited but the concern about a bruise had not been identified.”
end of life care
1 finding
minor“It was not always evident in people's care plans what their needs or preferences were when they were nearing the end of their life.”