critical“Medicines records were not accurately maintained and staff did not receive refresher training in medicines management.”
critical“the main and the witness MAR charts did not correlate and there were discrepancies between the two.”
care planning
2 findings
critical“Risk assessments for people were either incomplete, did not sufficiently identify all the areas of risk or were not reviewed regularly.”
moderate“Some care records had not been reviewed in line with the provider's own policy. For example, some support plans had not been reviewed since November 2019.”
governance
2 findings
critical“The provider did have an action plan in place, however this was not effective in addressing the issues that were identified in the provider's internal audits.”
critical“The provider had failed to notify CQC of some incidents where the police had been called.”
consent capacity
2 findings
moderate“There was no mental capacity assessment in place in relation to this person's living arrangements.”
moderate“restrictions... amounted to a deprivation of their liberty. Although it was evident that these restrictions had been put in place by the social workers and were in their best interests, there was no community DoLS in place.”
staff training
1 finding
moderate“the dates shown on the staff training matrix did not correlate with the dates on the individual training certificates seen.”
supervision appraisal
1 finding
moderate“formal supervision sessions were not consistently completed... she acknowledged they were not always meeting these targets.”
person centred care
1 finding
moderate“However care was not always person-centred.”
communication with families
1 finding
minor“I would like more contact [from the registered manager] but she is contactable... We get very little feedback from [registered manager]”
record keeping
1 finding
moderate“records were not completed appropriately and we could not be assured they were effective in always capturing areas of support that people needed.”