critical“no record of the assessment of the person's capacity to make this decision, or any record of an associated best interests meeting”
critical“nominated individual and manager were still not clear about their responsibilities to assess people's capacity...relied on local authority social workers”
critical“One person was being unlawfully restricted and had been for a prolonged period of time. There had been no applications to the Court of Protection.”
governance
2 findings
critical“care plan audits...reflected there were no changes required despite some information being out of date or no longer relevant to the person.”
critical
“There were no audits in place for care plans, daily care records or medicine records. Therefore, concerns and areas to improve had not been identified.”
medication management
2 findings
moderate“most recent medicines audit was March 2023...did not reflect that daily administration of medicines had been reviewed”
critical“MARs had multiple unexplained gaps in recording, medicines were recorded as being given at the incorrect time and there was regular recording of people being overdosed.”
record keeping
2 findings
moderate“information about people's mental capacity to make specific decisions was not always consistent or up to date”
moderate“Some people's daily notes did not record the times calls took place so there was no audit trail.”
care planning
2 findings
moderate“1 person who was not receiving care in line with their assessed need. Records reflected the person was not always being supported safely with their mobility.”
critical“People had basic care plans in place, but these did not cover all aspect of people's needs or risks. People did not always have individualised care.”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post...third consecutive inspection where this key question has been rated either requires improvement or inadequate.”
critical“The service had been without a registered manager for a significant period of time. The last registered manager had left in July 2020.”
staff competency
2 findings
minor“gaps in employment history which the provider had not investigated”
critical“Staff were not recruited safely. Some staff had no evidence their Disclosure and Barring Service (DBS) records checked.”
staff training
1 finding
critical“Staff did not receive enough training to be effective in their role. The provider had no way of tracking the training staff had received, such as a training matrix.”
safeguarding
1 finding
critical“We could not be sure concerns would always be identified and reported as there was a lack of systems in place to review people's care.”
incident learning
1 finding
critical“There were no systems in place to review accidents or incidents. No checks were made to see if there were any trends, or anything which could be learned.”
infection control
1 finding
moderate“Care staff did not always wear appropriate PPE masks in the presence of people, and we could not be sure masks were always of the appropriate quality.”
supervision appraisal
1 finding
moderate“Staff did not have supervisions so were not given the regular opportunity to discuss their opinions on a private basis.”
end of life care
1 finding
moderate“There were no end of life care plans in place and people had not been given the opportunity to discuss their end of life wishes.”
person centred care
1 finding
minor“Two people had bowel monitoring charts put in place, which were later stopped. The acting manager said they had put them in place for everyone — a lack of individualised care.”
complaints handling
1 finding
minor“People and relatives did not always know how they could complain about the service they received.”