critical“Some people's care plan and risk management plans referred to other people (who used the service) within their care record.”
moderate“A person's care plan contained conflicting information for staff about how to assist a person with dementia with their medicines. This had not been identified by the registered manager.”
record keeping
2 findings
critical“Care records did not always contain accurate information. For example, one person's risk management listed they were diabetic. However, the person was not diabetic.”
critical“Application forms had not always been fully completed by applicants. For example, there were gaps in employment histories that had not been addressed.”
governance
2 findings
critical“Delegated audits of medicine administration records had identified areas that required improvement... monthly audits continued to find the same areas and same staff.”
critical“Systems had not been established to ensure effective quality checks were completed as required. This placed people at risk of harm. This was a breach of regulation 17.”
staff training
2 findings
moderate“Staff also undertook specific tasks, such as stoma care, which the provider had not given them training in or assessed staff competency in.”
moderate“One staff member had commenced employment during September 2022 but still had 8 training topics to complete. This included key training topics including infection control.”
staff competency
2 findings
moderate“Neither the registered manager or provider had a current recognised qualification in moving and handling to enable them to assess whether they were using safe practices.”
moderate“Medicine competency assessments were not completed by the registered manager to assess staff's safe handling of medication.”
communication with families
2 findings
moderate“The registered manager and provider were not aware of their responsibilities under the Accessible Information Standard.”
minor“One relative told us, 'We cannot always understand what the staff are saying due to their spoken English.'”
incident learning
2 findings
moderate“The provider had handled 1 incident as a complaint and not identified the allegations as reportable.”
minor“Whilst the registered manager could tell us about actions that had been taken, they had not always recorded actions and outcomes on their incident report.”
medication management
1 finding
minor“Some people were prescribed topical medicines such as creams. Whilst these were recorded on their MAR, there was no body map in place to direct staff where to apply creams.”
complaints handling
1 finding
moderate“One relative told us, 'Following a complaint, I requested the managers do not send a specific staff member to the care call, but they continue to do so.'”
person centred care
1 finding
moderate“The provider had directed care staff to 'toilet train' one older person living with dementia.”
leadership
1 finding
minor“The provider had failed to display their rating from their last inspection on their website as required.”
safeguarding
1 finding
critical“The provider had acted outside of their service user bands and accepted a package of care to support a person with a learning disability... did not give staff training in learning disabilities.”
staffing levels
1 finding
critical“Staff were not always recruited in a safe way. We identified shortfalls in pre-employment checks undertaken by the registered manager.”
consent capacity
1 finding
moderate“A person was living with dementia and experienced anxiety, confusion and memory loss...but had no mental capacity assessment in their care plan to guide staff around consent to care.”
end of life care
1 finding
minor“Care plans around people's future wishes for their care, and where they wished to be cared for, had not been explored.”