Little Hayes

“During the assessment we spoke with 2 relatives, and 6 members of staff including the registered manager. We observed care and reviewed people’s risk assessments, care plans and medication administration records. We reviewed policies, procedures, training records, incident records and other relevant documentation.”

“The provider was in breach of 5 legal regulations related to the need for consent, safe care and treatment, premises and equipment, notification of other incidents and good governance of the service.”

“There was a lack of effective oversight and monitoring of the service. The provider’s governance processes did not identify the issues we found during this assessment. Quality assurance systems and processes were not effectively implemented to ensure safety and drive improvement.”

“The provider did not always ensure risks to people were assessed and managed. People’s care plans lacked guidance in relation to risks associated with individual’s diagnosed health conditions.”

“The provider did not have robust processes in place to identify potential health and safety issues. The provider had not ensured all risks to people had been mitigated and managed, for example, exposed hot water pipes, radiators without covers and window restrictors. Whilst there was a wide range of audits completed, these did not identify all the issues we found.”

“The provider failed to ensure that medicines were always stored and managed safely. Guidance for ‘as required’ (PRN) medicines did not always have accompanying written information, such as PRN protocols or person-centred guidance, to support staff in administering them safely and appropriately.”

“Where people lacked capacity to consent to their care and treatment, mental capacity assessments and best interest decisions had not been completed in accordance with the Mental Capacity Act 2005.”

“Staff and members of the management team were observed to be kind, caring and respectful in their interactions with people.”

“We have asked the provider for an action plan in response to concerns found at this assessment in relation to the need for consent, notification of other incidents and safe premises and equipment.”

“In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.”

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