critical“Systems had not been established to ensure safe and effective administration of medicines. This placed people at risk of harm. This was a breach of regulation 12.”
critical“Multiple records showed people did not receive their medicines as prescribed. For example, there were no records to show 2 people received their medicines for several days.”
governance
1 finding
critical“The providers monitoring systems did not identify the action needed to improve the quality and safety of the service. Not all shortfalls found at this inspection were already known or acted upon.”
incident learning
1 finding
critical
“Lessons were not always learnt. The provider took some action to reduce the risk to people following recent incidents involving skin integrity. However, this was not fully robust.”
safeguarding
1 finding
critical“When safeguarding professionals made recommendations, action was not always taken in a timely manner to reduce the risk of similar incidents occurring.”
care planning
1 finding
moderate“Care plans that were in place lacked person centred detail. People's care needs were not always effectively reviewed to ensure care plans remained relevant and reflected their needs.”
consent capacity
1 finding
critical“Consent to care and treatment had not been obtained in line with the principles of the MCA. This meant people were at risk of not having their human and legal rights upheld.”
record keeping
1 finding
minor“A complaints management system was in place, however not all records were well maintained.”
staff competency
1 finding
critical“Not all staff had their competency to administer medicines assessed. This meant there was a risk medicines could be administered by staff that did not have the skills to do so safely.”
communication with families
1 finding
minor“Some people described communication difficulties with office staff.”
leadership
1 finding
moderate“Leaders lacked awareness of best practice guidance in relation to supporting people with a learning disability and autistic people.”
person centred care
1 finding
moderate“There was limited focus on positive behavioural support planning to better meet the needs of people with a learning disability and autistic people.”