critical“Records such as mental capacity assessments and best interest decisions were not in evidence.”
minor“new staff were required to have two references but the staff that had transferred over from the previous agency did not have two references”
moderate“Staff's understanding around this area required improvement. We recommended the provider researches and implements best practice guidance to ensure specific decisions made in people's best interest are appropriately recorded.”
governance
2 findings
critical“Systems and processes had not been robust in identifying gaps in service provision and improving practice.”
minor
“The service had not yet completed a whole service audit which they had planned to do in June 2015 but individual audits were undertaken”
consent capacity
2 findings
critical“We found two stage capacity assessments in some of the care files we looked at but they were absent in others, when the information indicated the person did not have capacity.”
moderate“The provider was completing mental capacity assessments and best interest decisions but these were not always recorded separately for each specific decision.”
staff competency
2 findings
moderate“Not all staff told us they had an assessment of their competency to move people safely and they had highlighted they required further training in this area.”
moderate“Staff confirmed they had received training in this area however their knowledge on how to apply the MCA to their work was not robust.”
supervision appraisal
1 finding
critical“Staff had not received supervision, appraisal and training to make sure competence is maintained and to acquire skills to carry out their roles.”
staff training
1 finding
critical“The registered provider was not meeting this standard in relation to supervision and appraisal...not all staff told us they had their competency to administer medicines checked.”
medication management
1 finding
moderate“The record did not always contain information to advise what the medicines were for and when they should be administered.”
safeguarding
1 finding
moderate“One person had started work three weeks before their DBS had been returned...there was no risk assessment in relation to this.”
complaints handling
1 finding
minor“Complaints or concerns...were not compiled and the registered provider was unable to show how they had analysed and responded to information gathered.”