critical“care plan had been updated to reflect that they took time specific medicines, it did not identify what medicine this was, or the risk associated with this”
critical“initial assessment identified they required support to administer their medicines, within their care plan it stated that staff were to prompt them to take medicine”
critical“care plans did not match the services medication policy...no MAR chart in place...The service did not have protocols to ensure the safe administration of 'as required' medicine”
care planning
2 findings
critical“People's care plans had not been reviewed in order to assess people's risks and needs and document the support people required.”
critical
“four peoples records we reviewed had not been included on the system until the day before the inspection. This included care plans, risk assessments and support tasks.”
incident learning
2 findings
moderate“We reviewed individual accidents and incidents and did not always see appropriate actions or outcomes documented...not clear what action the service had taken to mitigate risks”
moderate“Records did not include further investigation or analysis to consider how incidents occurred or identify any actions which could be taken to try to prevent a reoccurrence.”
governance
2 findings
moderate“Not all of these actions had been completed at this inspection, which indicated further concerns about the effectiveness of the provider's quality assurance and governance systems.”
critical“Quality systems were not effective or robust in identifying and driving improvement across the service. The shortfalls we found during our inspection had not been identified by the provider.”
safeguarding
1 finding
critical“some incidents and safeguarding concerns were not recorded or passed onto the relevant authorities to ensure they were investigated properly”
record keeping
1 finding
critical“Electronic records did not contain a complete and contemporaneous record in respect of each service user.”
person centred care
1 finding
moderate“Asked for female carers but there's not many available. Most staff are men, female staff are very few and far between.”
consent capacity
1 finding
moderate“one person using the service was living with vascular dementia and had their medicines locked away. There was no mental capacity assessment or best interest documentation in place.”
complaints handling
1 finding
moderate“one relative that they had raised a concern regarding a missed dose of medicine. There was no record of this on the complaints log.”
infection control
1 finding
minor“feedback from relative that staff did not always use the correct personal protective equipment (PPE).”
leadership
1 finding
moderate“people we spoke to - including staff - were not always aware of who the registered manager was...the Registered Manager was not always visible, working one day on site a week.”
supervision appraisal
1 finding
minor“We saw examples of supervision being carried out for staff; however documentation was not always specific to individual staff.”