critical“Notifications were not always submitted as required...This is a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”
critical“Systems had failed to identify that mental capacity assessments were not fit for purpose...The above constitutes a breach of Regulation 17 of the HSCA 2008.”
medication management
1 finding
moderate“Medicines that are needed 'as and when required'...did not always have additional guidance for staff to help them identify when it may or may not be required.”
staffing levels
1 finding
moderate
“Staff were having to pick up extra calls due to staff shortages and sickness which had an impact on their ability to get to calls on time.”
care planning
1 finding
moderate“Details about people's specific health conditions were not always included in people's care plans which left people at risk of receiving inconsistent care.”
consent capacity
1 finding
moderate“The capacity assessment documentation in place was not fit for purpose as they did not include all of the principles of the MCA.”
staff training
1 finding
moderate“They sent two staff who just didn't know what to do. They [staff] should have proper training before they come to us.”
record keeping
1 finding
moderate“Care plans did not always contain enough detail...people's care plans did not include details about how people needed to be supported with this.”
end of life care
1 finding
minor“There was no detail in the person's plan about their end of life wishes or how they would like to be supported.”
incident learning
1 finding
moderate“There was minimal analysis of accidents and incidents...no further evidence of looking at particular trends such as the staff involved, day of the week.”
person centred care
1 finding
minor“People were not always aware of who would be providing their care and they were not informed of changes to the staff scheduled to support them.”
cultural competency
1 finding
minor“It was not evident that people were offered the opportunity to discuss their sexuality...Sexuality, religion and spirituality is very important.”
supervision appraisal
1 finding
moderate“Competency checks had only been conducted with reablement staff; the staff supporting people with longer-term care...were awaiting their competency checks.”