moderate“Record keeping was not up to date and audits to assess the quality and safety of the service as a whole were not as regular or sufficiently robust.”
governance
1 finding
moderate“Severe staffing pressures in relation to staff recruitment, retention and sickness had resulted in reduced management time impacting temporarily on governance and oversight of services.”
consent capacity
1 finding
moderate“we found a lack of recorded consent on people's care files and mental capacity assessments had not been completed for all aspects of the persons care and support”
staff training
1 finding
moderate“A number of staff told us they were supporting people with behaviours that challenge and they had not had training in this area.”
staff competency
1 finding
moderate“Competency checks help to ensure staff have the necessary skills, to carry out their roles. These were not up to date for all staff.”
supervision appraisal
1 finding
moderate“spot checks were not happening and supervision of staff varied in quality and frequency across the different sites.”
staffing levels
1 finding
moderate“Recruitment and retention of staff remained a significant challenge for this provider... staff sickness and vacancy rates had impacted on the quality of the service provision.”
infection control
1 finding
moderate“There was insufficient oversight of staff practice in relation to their infection control practices.”
end of life care
1 finding
minor“Staff had not received end of life training and people's advance wishes were not always recorded.”
medication management
1 finding
minor“prior to this incident the provider had not considered risks associated with aspiration and medicines for those on a softer diet.”
care planning
1 finding
moderate“we were unable to see evidence of how people were actively involved in planning and reviewing their needs... care and support plans did not record regular outcomes for people.”
communication with families
1 finding
minor“Relatives told us Mencap had not asked them for regular input or feedback about the quality of the service provided.”