critical“Quality assurance audits of had not been effective in identifying the issues we found during our inspection.”
critical“This is a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.”
person centred care
2 findings
critical“The failure to provide person centred care which reflected the person's personal preferences and needs was a breach of Regulation 9”
moderate“Two of the seven care plans we viewed contained out of date and inaccurate information.”
record keeping
2 findings
moderate“we found there was insufficient auditing of people's care records.”
critical“The failure to maintain accurate, complete and contemporaneous records for each service user is a breach of Regulation 17”
staffing levels
1 finding
critical“There were an insufficient number of staff to meet the needs of those using the service”
missed or late visits
1 finding
critical“Missed calls - sometimes no calls at all for the whole day.”
medication management
1 finding
critical“one person's MAR we reviewed, which covered August 2018, identified there were 13 gaps in recording, by seven different staff members.”
incident learning
1 finding
moderate“The registered manager had not taken sufficient steps to ensure lessons were learned when things went wrong.”
complaints handling
1 finding
critical“improvements had not always been made as a result of complaints... steps had not been taken to learn lessons from the complaints received”
communication with families
1 finding
moderate“people did not always know who was visiting and were not always able to choose who they were supported by.”
leadership
1 finding
moderate“the regional director did not have oversight of our concerns.”
care planning
1 finding
moderate“Care records were not consistently personalised nor did they contain all the knowledge from staff working with them at each care call.”
other
1 finding
critical“People's safety in the event of a fire within the extra care housing scheme had not consistently been assessed or mitigated.”
consent capacity
1 finding
moderate“Records to show how decisions were made on behalf of people who lacked capacity did not always evidence how particular decisions were made in their best interests.”