moderate“People's care plans and support documents were not consistently person centred and did not always provide detailed information on how to meet people's care needs, preferences and choices.”
minor“Where a person had been identified as being prone to falls, a detailed falls risk assessment was not put in place to assist staff in supporting the person safely.”
governance
2 findings
moderate“Audits within the service were not clear and did not identify the areas for improvement we found during inspection. The provider's current audits did not cover people's care records.”
moderate“The manager was not fully aware of their responsibilities under their registration. They had also not reviewed the provider policies in relation to reportable incidents.”
end of life care
1 finding
moderate“People did not have end of life care plans in place to ensure they receive personalised care in line with their choices at the end of their life.”
record keeping
1 finding
moderate“There were multiple areas of recording which needed improvement in the service this including end of life plans, capacity assessments, care records and staff members employment history.”
consent capacity
1 finding
minor“Some of the records were unclear and needed review. We recommended the provider reviews their current consent and capacity forms to ensure a clear capacity assessment and best interest record is in place.”
staff competency
1 finding
minor“We found some members of staff had incomplete or gaps in their employment history. The registered manager took swift action to address this during the inspection.”
incident learning
1 finding
moderate“The provider was not aware of their duty to notify the CQC when incidents occurred.”