critical“we saw one person had a wound on their body, but it was not clear whether they had ongoing skin integrity issues.”
critical“the social worker for one person had conducted a mental capacity assessment...but they had not requested a copy of this for their file. Their care plan had been signed by this person's next of kin, but they had not determined whether this person had the legal authority to sign th”
moderate“one person's care record did not specify that they were unable to communicate verbally. Another person's care record did not include details of a previous procedure they had undergone”
critical“logs were not always being completed in full, were not always legible and often lacked sufficient information”
minor“staff were not always following the provider's policies and procedures in relation to the management of people's finances.”
care planning
4 findings
critical“we found in records that had not been updated, there were indications of risk, without clear risk management guidelines in place.”
moderate“Care records contained very limited details about people's current healthcare needs and their healthcare histories if these were not directly connected to the care being provided.”
critical“A fifth person's care plan contained information pertaining to an entirely different person.”
moderate“a support plan was yet to be completed, despite staff supporting this person since 20 February 2019.”
governance
3 findings
moderate“at the time of our inspection had not taken timely action to ensure all risks had been managed.”
moderate“whilst the registered manager told us and records confirmed that people's support plans were reviewed every six months, the issues we found had not been identified.”
critical“Quality assurance systems in place were not always effective and we saw no evidence of auditing taking place in relation to people's care documentation”
medication management
2 findings
critical“MAR were not in use to evidence the effective management of people's medicines.”
critical“we received a notification informing us of an alleged incident relating to missed medicines...occurred on 11 January 2019.”
other
1 finding
critical“we saw a record for a person who was not at risk of choking, but their risk assessment had incorrectly recorded that they were at risk of choking.”
consent capacity
1 finding
critical“care records did not always record where people did not have capacity to make decisions. This was a breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
person centred care
1 finding
minor“one person's care record stated they required personal care, but did not specify exactly what their individual needs were or what action staff should take to meet these.”
missed or late visits
1 finding
moderate“electronic call monitoring (ECM) systems were not operating effectively and available data about the timeliness and completion of visits was inconsistent.”
safeguarding
1 finding
moderate“we were not always being notified of concerns in a timely manner...a notification relating to a missed medicines event that occurred on 11 January 2019.”
incident learning
1 finding
moderate“staff had recorded...that they had vomited and were not feeling well...nothing recorded in the log to confirm that staff had taken appropriate action”