critical“one medicine was prescribed twice a day, but records showed occasions when it had been given three times a day... there had been an error with one person's medicines, in which they had been given too much.”
care planning
1 finding
moderate“Care planning was often task orientated and did not reflect people's individual needs... the electronic care planning system in place prioritised tasks, rather than promoting personalised care.”
record keeping
1 finding
moderate“Staff had not always fully completed the medicine administration records. This did not show whether people had received their medicines or not.”
staffing levels
1 finding
moderate“Records showed some staff were working excessive hours... One staff member worked 146 hours in a two-week period... These risks had not been considered.”
staff competency
1 finding
critical“Systems were not in place to ensure all staff recruited had the qualifications, competence, skills and experience necessary for their work. Regulation 19(1)(a)(b)(2)”
supervision appraisal
1 finding
moderate“Records did not show staff had received regular meetings with their supervisor to discuss their performance or any concerns they might have. Formal supervision had slipped.”
governance
1 finding
critical“Audits were taking place but not always identifying shortfalls in the service... including those related to risk management, care planning and the management of people's medicines.”
consent capacity
1 finding
critical“Assessments of a person's capacity to consent to restrictive practices such as bed rails, sensors and alarms had not been undertaken. Information did not show whether least restrictive options had been considered.”
complaints handling
1 finding
moderate“The provider's complaint procedure had not been followed in response to these concerns. The complaint had not been acknowledged or investigated and action had not been taken.”
person centred care
1 finding
critical“Care planning did not always demonstrate people's needs and the support they required. This was a breach of regulation 9 of the Health and Social Care Act 2008.”
communication with families
1 finding
minor“Sometimes there are communication problems. Some staff speak too quickly... Accents and wearing a face mask do not help.”
incident learning
1 finding
critical“There had been an error with one person's medicines... Immediate action to ensure the person's well-being had not been taken and there had not been an investigation.”
leadership
1 finding
moderate“There was a lack of management oversight. The provider was not aware of the complaints which had been made, or that action had not been taken to address them.”