critical“The provider failed to maintain accurate and complete records in relation to the service and people's care. This placed people at risk of harm. This was a breach of regulation 17.”
consent capacity
1 finding
critical“Mental capacity had not been appropriately assessed and recorded. This is a breach of regulation 11 of the Health and Social Care Act (Regulated Activities) Regulations 2014.”
care planning
1 finding
moderate“Risk assessments did not always contain the necessary detail to ensure staff had all information needed to keep risks to people at a minimum.”
end of life care
1 finding
moderate“People being supported with care at the end of their life did not have any care plan or record to ensure consideration was to be given to people's preferences.”
communication with families
1 finding
moderate“The carers English is not good, and we can only understand a few of them. They don't always understand [loved one] either.”
governance
1 finding
moderate“Audits and governance systems were not always effective. Systems relating to care records had not identified concerns found during inspection.”
staff competency
1 finding
moderate“We could not be assured staff were competent to use equipment or administer medicines safely. We were told the provider carried out competency assessment, but no records were provided.”
leadership
1 finding
minor“Not everyone we spoke with was able to tell us who the manager of the service was and not all described the service as well led.”