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.”
consent capacity
1 finding
critical“For people assessed as lacking mental capacity for certain decisions, DoLS were not in place. We were told there were 3 in progress but the status of these was unclear.”
care planning
1 finding
moderate“The registered manager did not have full oversight of people's care plans and risk assessments. Reviews were completed by the team leaders, but we saw little evidence these had been audited.”
staff competency
1 finding
moderate“Competencies were completed during induction but not completed again unless there was an issue, this is not in line with NICE guidance which state staff should have an annual review.”
staffing levels
1 finding
moderate“People's relatives did not feel there were always enough staff. They described people not going out or being supported by different staff which could be unsettling.”
incident learning
1 finding
moderate“We reviewed some incident reports and found they did not reflect on what led to the incident and what could be done to prevent it in future.”
person centred care
1 finding
minor“People's care plans included language which was childish, such as describing them as 'playing' or 'being cheeky'. A person's care plan stated a person 'Played with their toys.'”
communication with families
1 finding
minor“People's families did not always feel involved in planning their care. A relative told us, 'We had very little input with the support plan.'”
record keeping
1 finding
moderate“The registered manager tended to monitor the service informally; there was limited documentation of this. The frequency of spot checks and what was to be checked at each visit was unclear.”
medication management
1 finding
minor“People's PRN protocols were not always clear. We reviewed one which stated a person would 'communicate they had pain' but did not say how.”