critical“People's capacity to make decisions was not assessed. The registered manager told us, "There probably should be but there aren't."”
critical“A person's food was locked away...cooker and hob were turned off...no mental capacity assessments or recorded best interest decisions.”
staff competency
2 findings
moderate“Two staff told us they would 'overrule' someone's wishes if they didn't think they were making a good decision.”
moderate“1 member of staff had undertaken tasks they were not trained for around pressure care.”
governance
2 findings
critical“There was no formal system to analyse records to identify patterns and trends and drive improvements in the quality of care.”
critical“There was no overall audit of staff recruitment, induction, competency checks, or supervision.”
record keeping
2 findings
moderate“Care plans and medicine administration records sheets weren't always up to date...stated staff were supporting them to take a medicine at a different time than prescribed.”
critical“There were no written risk assessments for catheter care or use of hoists.”
care planning
2 findings
moderate“Risk assessments did not always contain information about what the risks were or what staff should do if something went wrong.”
critical“Care plans did not always contain the detailed guidance staff needed to keep themselves and others safe.”
incident learning
1 finding
moderate“The registered manager hadn't separately recorded incidents and accidents, and actions taken. There were no audits of incidents or accidents.”
supervision appraisal
1 finding
moderate“Supervision had not occurred for 6 months. The registered manager told us "It's fallen by the wayside during the pandemic."”
other
1 finding
minor“The provider had not identified where DBS checks had not been re-done for staff employed for many years.”