moderate“only one of the audits received was identified on the annual planner as for completion in November 2019... audits did not identify any concerns.”
moderate“audit of care plans which were audited twice in the year... Regular care plan audits were required to ensure all the information was available for staff.”
moderate“At our last inspection we found that the way the registered manager monitored the quality of the service people received needed to improve. This was a breach of Regulation 17”
moderate“medicines had not always been audited and accidents and incidents were not reviewed to see where areas of risk could be reduced”
infection control
4 findings
minor
“there was no hand sanitiser at the entrance and not all procedures were being followed.”
minor“waste bins did not all have lids. Red bags were not available to ensure adequate separation of soiled laundry.”
minor“We recommended that the registered manager should implement infection control policies and procedures”
moderate“infection control audits were not in place and that no one was responsible for taking a lead on infection prevention”
incident learning
2 findings
minor“Accidents and incidents were recorded, and action was taken to address any concerns. These were not analysed at service level.”
moderate“accidents and incidents were recorded, but audits were not carried out to look at ways in which risks could be reduced”
staff training
2 findings
moderate“the provider had breached Regulation 12...in relation to the lack of staff training and meeting people's nutritional needs”
critical“large numbers of staff who had not completed training around the MCA and DoLS, managing challenging behaviour, fire safety, manual handling, infection control and hand hygiene”
care planning
2 findings
moderate“people's care records lacked nutritional assessments for people who were diabetic and there was not a structured approach to show that staff could recognise and manage the condition”
critical“care records lacked nutritional assessments for people who were diabetic and there was not a structured approach to show that staff could recognise and manage the condition”
medication management
1 finding
moderate“when they were handwritten they were not always signed and rarely by two people... Some bottles and creams had not been dated when opened.”
record keeping
1 finding
minor“records were not always updated to include the action taken... There were not any records for fire drills which showed the home's procedure had been followed.”
leadership
1 finding
moderate“staff were unable to explain to us what the provider's vision and values were... the service did not have clear vision or a core set of values”
consent capacity
1 finding
moderate“large numbers of staff who had not completed training around the MCA and DoLS”
person centred care
1 finding
minor“residents did not contribute to the development of the menus... people had not been consulted about the changes that would be made”