minor“It was not always easy to find the relevant details in a person's care plans and risk assessments, as both paper and electronic formats were still in use.”
critical“in one record there was no contact details for the person's next of kin, no daily schedule, no information around MCA and no risk assessments”
moderate“there were inconsistencies in the recording of the administration of medicines on the Medicine Administration Record (MAR) sheets.”
moderate“eight people used bed rails to keep them safe in their beds, but the risk assessments for these and the accompanying guidance for staff was incomplete.”
governance
4 findings
critical
“At our last inspection the provider had failed to demonstrate good governance. Action had been taken to make improvements.”
critical“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17”
critical“They had not fully developed quality assurance systems and audits which would help them to consistently ensure the service was running well.”
moderate“improvements were required to the quality assurance systems...medication audits were completed on a regular basis and that daily records were reviewed to ensure that care had been delivered as per people's requirements.”
supervision appraisal
3 findings
moderate“Staff were not receiving supervision at the intervals detailed in the supervision policy”
moderate“not all staff benefitted from regular formal supervision...there were gaps and inconsistencies which needed to be addressed.”
moderate“there were no formal systems in place to review staff competence and their performance on a regular basis...this was on an informal basis and lacked structure in timing and the issues discussed.”
consent capacity
3 findings
moderate“where a person had been deemed to lack capacity to consent to aspects of their care, there continued to be limited documentation around best interest decisions”
moderate“it was unclear as to which specific decisions the person may lack capacity in...there was no documentation to support where best interest decisions needed to be made.”
moderate“two people that did not have the capacity to make a decision about the use of bed rails had these in place...had failed to follow the procedures and have written documentation in place regarding their use.”
care planning
3 findings
moderate“Care records lacked detail as to how risks identified to people's care were mitigated, there was lack of documentation around people's mental capacity”
critical“although the risk had been identified there was no written risk management plan in place which gave detailed instructions as to how staff needed to support people to mitigate any risk.”
moderate“after one person had fallen, their risk assessment had not been updated to reflect what had happened, and the measures that were in place to try to reduce a similar event.”
staff training
1 finding
moderate“training had not been regularly refreshed which meant the provider could not be assured staff were following best practice”
safeguarding
1 finding
moderate“staff training in relation to safeguarding had not been kept up to date which meant the provider could not be assured staff had the full understanding”
incident learning
1 finding
moderate“there was insufficient information recorded on people's care records to direct and guide the staff of any actions they needed to take.”
staffing levels
1 finding
moderate“efforts to obtain individual references for the staff had not been forthcoming. Whilst the registered manager had considered a risk assessment...this had not been documented in each staff file.”
leadership
1 finding
moderate“the registered manager had a full understanding of all requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”