critical“The person's risk assessments did not contain enough guidance for staff to mitigate the risks identified.”
consent capacity
1 finding
critical“The person's care record did not include any mental capacity assessments. It was not clear how the registered manager determined when a mental capacity assessment was needed.”
governance
1 finding
critical“The provider's systems and processes to monitor the quality and safety of the service were not always effective. This was a breach of Regulation 17.”
staff training
1 finding
moderate“The registered manager had not always ensured new staff completed mandatory training prior to starting work.”
staff competency
1 finding
moderate“Staff had not all received practical face to face training in moving and handling and competency assessments were not completed.”
medication management
1 finding
moderate“The registered manager had not always ensured staff received medicines training prior to starting work and there was no timeframe for completion of medicines competency assessments.”
end of life care
1 finding
minor“The person's record did not include any information about their wishes at the end of their life. Staff had not received training in end-of-life care.”
record keeping
1 finding
moderate“The registered manager did not have clear documentation of input from other professionals. The registered manager did not have full oversight of incidents at the service.”
incident learning
1 finding
moderate“We were originally told there had been none, then received several forms completed by staff. These had been reviewed by the manager but had not been collated anywhere for analysis.”
staffing levels
1 finding
moderate“The person's care record contained conflicting information relating to the care required and staff available on the rota at night.”