critical“Staff had not had their competency to handle medicines fully assessed and there was a lack of clear information about current medicines and the support that people required.”
critical“staff had signed four times a day for a medicine that was only to be given in the mornings. An incorrect code had also been used in the MARs”
critical“lists of people's current medicines were not in place and medicines administration records (MARs) had not always been accurately completed”
record keeping
3 findings
critical“Medicines administration records (MARs) were inaccurately completed and there was no system of auditing the MARs to identify any errors or shortfalls in recording.”
moderate
“There was no current system for auditing the MARs and we concluded that people could not be fully assured of receiving their medicines safely.”
minor“Information about people's food likes and dislikes was not available. The registered manager told us this would be addressed.”
staff competency
1 finding
moderate“there was no means of ensuring a full assessment of each staff member's competency was carried out”
safeguarding
1 finding
critical“three allegations of neglect in recent months which had involved care and support visits being missed...safeguarding issues were reported retrospectively during the inspection”
staff training
1 finding
minor“no training had been provided for staff in the MCA to make sure they understood the implications for their practice”
supervision appraisal
1 finding
moderate“The manager acknowledged individual supervision for staff had lapsed prior to them being in post”
care planning
1 finding
moderate“Care plans did not all show steps to take to mitigate risk where it had been identified. For example, a risk of falls or distressed behaviours.”
governance
1 finding
moderate“A formal system was not in place to check that identified actions were carried out and to audit the registered manager's audits.”
consent capacity
1 finding
minor“We discussed this should be a separate, in-depth course and not just as part of the Care Certificate.”