minor“The provider did not always keep accurate up to date records when best interest decisions had been made. One person did not have access to their kitchen, although a best interest meeting had taken place, there was no record of the decision-making process.”
moderate“Records failed to reflect care was being delivered as directed within people's care plans. We could not be assured that people's care was being delivered in line with the care plan.”
consent capacity
2 findings
minor“We recommend the provider reviews best practice guidance in relation to the recording of best interest decisions and updates their practice accordingly.”
critical“The provider failed to ensure that care and treatment was provided with the consent of the relevant person. This was a breach of Regulation 11.”
staffing levels
1 finding
critical“The provider failed to have sufficient staff to meet people's needs, this is a breach of Regulation 18, (Staffing) of the Health and Social Care Act 2008.”
governance
1 finding
critical“There failed to be effective systems in place to monitor and improve the service. Records were not clear or consistent. This was a breach of Regulation 17.”
person centred care
1 finding
critical“Failure to provide person-centred care was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008.”
care planning
1 finding
moderate“Key information about people's behaviours and triggers were not always included within the care plans. This meant people, new staff or agency staff were put at risk.”
safeguarding
1 finding
critical“Some people were placed at risk of abuse and restrictive practices due to staffing levels and unmet needs. We made referrals to the local authority safeguarding team.”
medication management
1 finding
moderate“Regular checks identified regular errors such as administration errors and incorrect stock levels. Lessons learnt were being considered but did not result in a reduction of errors.”
infection control
1 finding
moderate“Some staff were not wearing masks when supporting people as per current government guidance which put people at risk.”
end of life care
1 finding
minor“People's end of life wishes were not explored and recorded. This was an area we would expect providers to approach with people and their families.”
staff competency
1 finding
moderate“Management demonstrated a lack of knowledge regarding the Mental Capacity Act. Professionals told us, for a specialist placement, the management lacked knowledge around the legislation.”
supervision appraisal
1 finding
minor“Some staff told us supervisions, debriefs and competency checks were rarely completed.”