critical“a recent audit had recorded no gaps in records when there were gaps in records seen...medicines were not always robust enough to keep people safe. This demonstrates a breach of Regulation 12”
critical“one person had been prescribed one medicine three times a day was only being supported to have it twice a day according to their MAR records. This had not been picked up by the provider.”
consent capacity
2 findings
critical“The provider was not acting in accordance with the MCA and were not following the Deprivation of Liberty Safeguards...a breach of Regulation 13”
critical“for one person there was concerns about locked doors and no MCA or best interest decision was in place to support this.”
governance
1 finding
critical“systems were either not in place or robust enough to ensure the quality and safety of the service was assessed and monitored effectively. Breach of Regulation 17”
care planning
1 finding
moderate“People's support plans did not always reflect their needs or demonstrate that the person's care had been reviewed. Checks to ensure that records were effective and up to date were not always completed.”
staffing levels
1 finding
moderate“high use of agency staff to cover the gaps in staffing and in one service we visited 90% of the staff were agency staff.”
record keeping
1 finding
moderate“some viewed were unclear when written, last updated or reviewed. One registered manager seemed surprised that there were concerns with the care plans.”
incident learning
1 finding
moderate“there was no indications they planned to investigate the errors in more detail and identify any lessons learnt. This placed people at increased risk of harm.”
leadership
1 finding
moderate“Not all the registered managers we spoke with were happy having the responsibility of being a registered manager...changes in leadership at the service and the high use of agency staff.”