critical“not all risks had been fully identified and care records gave contradictory or missing information that could lead to people being placed at risk of harm”
safeguarding
1 finding
moderate“staff did not have a good understanding what different forms of abuse looked like. This meant there was a risk of some abuse not being identified or reported.”
staff training
1 finding
critical“They lacked knowledge of conditions such as dementia and diabetes despite supporting people with these conditions and told us they had not received training in diabetes.”
staff competency
1 finding
moderate“Staff were not aware of the principles of the Right support, right care, right culture policy. They did not understand what sensory or communication strengths or impairments a person might have.”
supervision appraisal
1 finding
moderate“supervision records showed they were not supported to check their competency, understanding of their role or how they applied best practice.”
medication management
1 finding
moderate“Medicine Administration Records (MAR) showed different medicines prescribed than those listed in the care plan. This could lead to medicine errors if staff did not have the correct information.”
governance
1 finding
critical“Quality assurance systems failed to identify or drive improvement in areas of quality, risk management, safety and staff skills and knowledge. This placed people at risk of harm.”
incident learning
1 finding
moderate“staff told us they were not given the opportunity to reflect when things went wrong. Records of staff supervision and team meetings showed staff were not given the opportunity to discuss areas for learning.”
end of life care
1 finding
minor“Staff had not yet had training in this area. People's wishes were not always assessed and in one case it simply stated to contact their relative for details.”
leadership
1 finding
critical“The registered manager did not have a sufficient awareness of the legal responsibilities of their role and current statutory and best practice guidance.”
record keeping
1 finding
moderate“Care records had inconsistent and or missing information about risks and people's conditions.”