critical“A patient had been without her glaucoma eye drops for 2 weeks, despite the fact that the staff had been signing the MAR chart saying it had been given.”
care planning
1 finding
critical“The care plans for 4 people living with a learning disability did not contain any details about how this impacted them or what potential risks it presented to them or others.”
staff training
1 finding
critical“Training records showed staff had not received specific learning disabilities, mental health needs or epilepsy training to support individuals effectively with their conditions.”
governance
1 finding
critical“The oversight and quality assurance processes had not identified the need for the development of some people's risk assessments.”
person centred care
1 finding
moderate“Some care plans lacked detail about people's physical and mental conditions and what staff should do to support these responsively.”
leadership
1 finding
moderate“Many people and staff told us that they felt that the culture and approach of management had dropped and had not been as effective since the registered manager had been absent.”
missed or late visits
1 finding
moderate“I have such a variety of times that they come - this morning it was near 10am I was up all night, so I got myself up. I never know what time it's going to be.”
infection control
1 finding
moderate“They don't wash their hands before they touch any food of mine. They don't wash their hands enough.”
staff competency
1 finding
critical“I had 2 staff members last year who didn't know how to use a hoist for another client. They told me that they were winging it and hadn't been trained to use it.”
record keeping
1 finding
moderate“We reviewed 4 people's MAR charts and identified a number of gaps where care assistants had failed to record whether a medicine had been administered or not.”