critical“Care plans did not always include relevant information for staff to follow. People's care plans were not person centred and did not include relevant information.”
medication management
1 finding
critical“Medicines were not managed safely. Multiple gaps were found in people's MAR's where topical creams were prescribed.”
governance
1 finding
critical“Medicines management audits had not been carried out since 2020. The registered manager failed to pick up concerns we found on inspection.”
record keeping
1 finding
critical“People's medicine administration records (MARs) were at times illegible. There were multiple unexplained gaps and controlled drugs were not appropriately recorded.”
incident learning
1 finding
moderate“An analysis of accidents and incidents had not been carried out. Patterns and trends could then not be identified, and lessons could not be learnt.”
safeguarding
1 finding
critical“We identified a person who could have been at risk of potential physical harm and abuse. An alert had been made to the local authority safeguarding but did not include relevant details.”
consent capacity
1 finding
critical“The registered manager had failed to recognise the need to carry out assessments of people's capacity...had not had any training in relation to MCA assessing.”
supervision appraisal
1 finding
moderate“Staff did not receive supervision in line with the provider's policy...staff had only received one face to face conducted by a peer.”
staff training
1 finding
moderate“Staff hadn't received training specific to people's needs. Staff had not received training in end of life care.”
end of life care
1 finding
critical“End of life care plans were not in place even though several people were receiving palliative care. Preferences and wishes were not discussed with people or their relatives.”
person centred care
1 finding
moderate“People's care plans lacked person-centred detail. Care plans were basic and did not include information such as life histories, personal wishes and aspirations.”
complaints handling
1 finding
minor“"Yes, I made a complaint, but there was no 'oh that is terrible,' an apology or feedback given. They just said 'oh, okay'."”
leadership
1 finding
moderate“The registered manager was not able explain to us what duty of candour meant. They were unaware of the details of the fundamental standards.”
staff competency
1 finding
moderate“Competence assessments including medicines administration were carried out by peers and additional training to carry out these assessments had not been completed.”