moderate“Staff had not started the Care Certificate. No information was available on staff files to demonstrate a robust induction had been completed.”
medication management
1 finding
moderate“The MAR chart was incomplete. It did not include the timings, the dose and strength for the medication.”
governance
1 finding
critical“Systems and processes were not robust enough to demonstrate safety and quality were effectively managed. This was a breach of regulation 17.”
staff competency
1 finding
critical“The registered manager had not completed the appropriate checks to ensure that staff were recruited safely into the service. Breach of Regulation 19.”
supervision appraisal
1 finding
moderate“Staff had received 1 supervision in August 2022. We did not see any other records of supervision or 'spot check visits'.”
care planning
1 finding
moderate“Care plans and risk assessments were incomplete and did not contain all relevant information.”
end of life care
1 finding
minor“The person's care plan did not include information about their end of life care wishes.”
record keeping
1 finding
moderate“We were unable to fully evaluate this as there was no evidence for a completed assessment kept in the person's care records.”
consent capacity
1 finding
minor“The person's care plan contained information about decisions they could make themselves; however, a written record to confirm this was not available.”