Coast Community Care

“We found 2 breaches of regulation.”

“People’s safety was not managed effectively. Not all care plans and risk assessment had been regularly updated. Some risk assessments were missing including those relating to epilepsy and for people living with substance dependency and related issues. Other risk assessments lacked any meaningful instruction to staff about actions they should take when things went wrong. These included people at risk of developing pressure sores. Staff training was lacking with up to 12 members of staff shown in need of urgent training in autism awareness, medicines and diabetes. No training had been completed for epilepsy. A person supported by the Speech and Language Team (SaLT) who was at risk of choking had recorded that they had been given cereals to eat which would have increased a risk of choking. This matter was immediately addressed by the registered manager. Some moving and handling equipment was overdue servicing.”

“The governance, management structure and auditing process had not been robust enough to identify and then address the issues found during this assessment. Reviews of care plans and risk assessments was inconsistent and did not always involve people and their loved ones. Auditing processes had not been robust enough to identify the missing or incomplete risk assessments, deficits in staff training or effective means of capturing feedback from people, relatives and staff.”

“The service did not consistently work well with other partners and there was inconsistency in people’s ability to provide feedback about the service. Not everyone had conversations about advanced decisions relating to their care in the future.”

“However, pre-assessment processes were robust and people had decision specific mental capacity assessments in place. People were supported by a caring staff team who treated them with respect and dignity and promoted their independence.”

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