moderate“where safeguarding concerns had been raised, the appropriate authorities had been notified but there was no information available on file to evidence that concerns were investigated”
minor“DoLS applications in place and the reasons for these, but there was no evidence of this on people's care files”
moderate“One person had three separate behaviour plans dating back to 2011, this meant staff did not have clear guidance to follow.”
medication management
2 findings
minor“the guidance on this lacked detail in order to ensure this medication was administered consistently”
critical
“We saw 32 gaps on the same person's medicine count sheet for one month. This practice puts people at risk of potential harm.”
complaints handling
1 finding
minor“recordings were inconsistent and the information available regarding individual investigations varied, depending on each location”
staffing levels
1 finding
moderate“There was a high use of agency staff and staff turnover meaning consistent care and support was not always delivered.”
staff competency
1 finding
moderate“Staff did not always have the skills or ability to support people effectively.”
consent capacity
1 finding
critical“Relatives were signing records to consent on people's behalf without the legal right to do so.”
care planning
1 finding
moderate“Care plans contained duplicate information and different versions of documents therefore, staff did not always have the most up to date information to follow.”
governance
1 finding
critical“Audits undertaken had failed to identify the issues we found at inspection. These included concerns with care plan, risk management, consent and medicines.”
incident learning
1 finding
moderate“Incidents were recorded at the end of the month but not analysed for patterns and trends.”
person centred care
1 finding
moderate“Staff could not always demonstrate they gave people choice and control and responded to their needs.”
infection control
1 finding
minor“The check had been completed by staff to say refrigerated food was in date, however we found out of date food in the person's fridge.”
end of life care
1 finding
minor“There was no information provided about end of life care.”