critical“People's care records and risk assessments were not comprehensive, did not always reflect people's care needs and were not always person-centred.”
governance
1 finding
critical“The provider did not have effective governance systems in place to assess, monitor and improve the quality and safety of people's care. This placed people at risk of harm.”
record keeping
1 finding
critical“On this matrix it stated that nearly all of the 17 staff had completed all their training courses on the same day. This was not possible as staff had different start dates.”
medication management
1 finding
moderate“The records used to record and monitor people's medicine management were not always completed appropriately.”
consent capacity
1 finding
critical“We asked the registered manager for copies of the person's care records and paperwork relating to this decision as they were not available during the inspection.”
person centred care
1 finding
critical“Care plans followed a standardised format with little evidence of person-centred care planning.”
end of life care
1 finding
moderate“The registered manager told us the person did not wish to discuss an end-of-life care plan and therefore there was not one in place. However, there was no record of this conversation.”
communication with families
1 finding
moderate“The registered manager was unaware of the Accessible Information Standard.”
cultural competency
1 finding
moderate“There was limited information within people's care records about their protected characteristics. The registered manager had limited understanding of the Equality Act 2010.”
incident learning
1 finding
moderate“Incidents records did not always include details of investigations completed and action taken to prevent reoccurrence.”
staffing levels
1 finding
moderate“During and following the inspection the provider had their overseas staff sponsorship license suspended and then removed... agency staff were used whilst permanent staff were recruited.”