critical“one person had a medication listed in their plan of care which told staff to give 1ml but immediately below this instruction was a different instruction to give 2mls”
critical“This person's body map showed the registered manager had directed staff to use two alternating skin sites every seven days. This was not in line with the manufacturer's instructions”
moderate“Where medicine was prescribed 'when required' we found no protocol with the medication administration information to guide staff when the medicine should be administered.”
care planning
2 findings
critical“Information in people's plans of care was sometimes contradictory and this posed potential risks of harm to people.”
moderate
“one person's plan of care stated in one section they were incontinent and would ask staff for support to use the toilet and another section stated the person was continent.”
governance
2 findings
critical“Governance systems failed to identify concerns with medicine administration information. Governance systems for care plan information were insufficient.”
moderate“Quality checks were undertaken but were not always effective in identifying where improvements were needed.”
record keeping
2 findings
moderate“their care plan section 'where is the DNACPR located' had not been completed.”
minor“some language in care plans referred to 'the service users' or 'the patient' where generic terminology or cut and pasted information had not been changed to the person's name.”
leadership
2 findings
critical“Since registration with CQC in February 2021, no statutory notifications had been sent to us... "There are at least ten I know I should have sent."”
minor“The registered manager had not yet started their Level 5 Care Leadership and Management Diploma.”
incident learning
1 finding
moderate“a staff member had crushed a person's tablets without first seeking guidance... there was no evidence this had been reported by staff to the registered manager as an incident.”
consent capacity
1 finding
moderate“the outcome of each assessment was generic and not person centred and stated, "where the individual lacks capacity then a best interest decision document would be completed".”