critical“MARs charts were handwritten without a second signatory, as per the providers policies and procedures. Variable doses were not always recorded.”
safeguarding
1 finding
critical“At one property, we found ten incidents of unexplained bruising which had not been correctly documented or reported.”
consent capacity
1 finding
critical“Staff told us: 'We don't do capacity assessments, that is not our role'. And: 'Only social workers do MCA assessments, I wouldn't do one'.”
governance
1 finding
critical“We could not find documented evidence that care files had been audited...the registered manager was not aware of issues around unexplained bruises not being reported.”
care planning
1 finding
moderate“There were also care plans that were vague or where needs had not been care planned at all...daily routines stated; 'wash hair etc'.”
supervision appraisal
1 finding
moderate“Some of the staff we spoke with said they had not received supervision for some time...One team leader told us that they had not undertaken supervisions for staff as often as they should have.”
incident learning
1 finding
moderate“'[Name removed] banged their head on the settee quite hard'…'large bump on left eye'. There was no accident report completed.”
record keeping
1 finding
critical“We were unable to locate care plans for two people...the files had been taken off the premises to be updated...staff at the property having no information about these people.”