critical“The mental capacity assessments were still not always decision specific. Some capacity assessments did not address areas relevant to the person's support provided by staff.”
moderate“Where people had capacity to make their own decisions but could not sign consent forms, those were signed by their family. There was no record of their own consent being obtained.”
critical“there were no records of mental capacity assessments or best interests' decisions for these people. Despite additional training undertaken by the registered manager, they were not able to tell us how they implemented MCA”
critical“The provider had failed to act in line with the Mental Capacity Act 2005 and the related code of practice.”
governance
4 findings
critical
“The governance system and processes in the service were not always effective in recognising shortfalls and ensuring appropriate action was taken to remedy them.”
moderate“The service improvement action plans were out of date and there were limited assurances around current improvement priorities for the service.”
critical“The registered manager failed to identify they were still not working in line with safe recruitment practices and their own policy in this area.”
critical“The provider had failed to establish and operate effective governance systems which impacted on people's care.”
safeguarding
3 findings
critical“On one occasion a potential safeguarding concern was not considered as such despite action being taken to mitigate the risks to the person at the time.”
critical“The provider's safeguarding policy was mistakenly naming the registered manager as external contact for safeguarding. This posed a risk of staff not knowing how to escalate concerns.”
moderate“they did not always follow the correct multiagency process and their own policy on reporting those to the local authority.”
record keeping
3 findings
moderate“The staff attendance monitoring system was not always used effectively... records showed a consistent absence of staff on one person's care visits.”
moderate“one person's plan could not be located at all. Another person's plan included out of date information on the changes made to the time of their care visits.”
moderate“Staff did not always keep accurate record of the support they provided with medicines.”
care planning
3 findings
moderate“Not all people had relevant information around their interests, life stories or advanced care wishes included in their care plans despite this being addressed as an area of need.”
critical“People's care plans had significant discrepancies and lacked information around their individual risks, needs and preferences.”
moderate“people's care records were not always detailed enough and robust to ensure all their personal needs were considered by staff”
incident learning
2 findings
moderate“Incidents were analysed in isolation without looking at possible trends. It was also unclear how the provider's safeguarding policy was considered when assessing individual circumstances.”
moderate“Due to lack of robust records it was unclear how the registered manager analysed and investigated those events and concerns.”
medication management
2 findings
critical“staff signed to state a medicine which was prescribed to be taken once a day was shown as administered twice a day. This was not identified in the medicines audit that month”
critical“Not all staff supporting people with their medicines received training to do so and were competency checked.”
staff competency
2 findings
critical“for two staff the declared employment did not match their references and where staff worked in previous roles in care, their references were not always obtained.”
moderate“Their competencies in respect of moving and handling or medicines administration were not checked at the point of the inspection.”
staff training
2 findings
moderate“Staff had not received any training relating to specific needs of the people they supported. For example, around dementia, communication, falls prevention, skin care or continence care.”
critical“Staff did not receive any specific training around supporting people living with learning disabilities and/or autism or supporting people living with dementia”
person centred care
2 findings
moderate“people's individual care and support plans did not always fully reflect those changes in practice. Care plans still lacked personalised detail on how people wanted to be supported”
critical“The provider had failed to ensure the care provided was always appropriate and reflected people's preferences.”
end of life care
1 finding
minor“Not all people had relevant information around their interests, life stories or advanced care wishes included in their care plans.”
missed or late visits
1 finding
critical“There have been a couple of incidents that I've had to phone the office for as nobody showed up on Saturday and nobody called us.”
staffing levels
1 finding
critical“The provider had failed to ensure there were always enough staff deployed to support people which put people at risk.”
leadership
1 finding
critical“I don't think the service is well-managed at all. I haven't got a clue who the manager is, the communication is very poor.”
complaints handling
1 finding
critical“The provider had failed to operate an effective system to identify, receive, record, handle and respond to complaints.”
communication with families
1 finding
minor“I've only got one number, and I can't understand what they're saying to a degree.”