critical“The MAR chart for one month contained the wrong information for the dosage of medication to be administered for one person. Audits completed by the provider and management had not identified this error.”
critical“provider was not ensuring that people were protected from unsafe management of their medicines. This was a breach of Regulation 12(2)(g) HSCA 2008”
moderate“Medicine checks took place regularly but systems for checking medicine records were not firmly embedded. The audit forms used to review medicines...were on a template designed for care homes”
supervision appraisal
3 findings
moderate“During the last year there had been gaps of up to nine months between supervision sessions. The manager stated that supervisions would normally be every two to three months.”
minor“the current schedule of planned supervisions needed to become more formalised as part of their improvement strategy in managing and supporting staff”
minor“Staff supervisions were regular, every eight weeks but there were no spot checks on staff performance...Annual appraisals were being planned.”
consent capacity
2 findings
critical“The correct procedures to restrict people's liberties in a lawful manner or make best interest decisions for them had not been followed. This was a breach of Regulation 11.”
critical“provider was not ensuring that people were protected from unlawful care as their mental capacity to make decisions had not been assessed. This was a breach of Regulation 11(3)”
care planning
2 findings
moderate“Although there had been a number of occasions when one person had shown behaviours which could challenge others, a risk assessment had not been put in place to address this issue.”
moderate“behavioural support plans were not in place for everyone we reviewed/discussed and had not been drawn up showing consultation with other health care professionals”
governance
2 findings
minor“remaining three staff surveys said that the communication was not provided when they needed it”
moderate“Audit tools were not fit for their current purpose and medicines records were not audited as often as the service said they should be.”
safeguarding
1 finding
critical“One safeguarding issue had been reported appropriately...no action had been taken to discuss the incident with the safeguarding team or to report the incident to the commission.”
complaints handling
1 finding
minor“The provider had a written complaints procedure but this was not in a format that was accessible by everyone who used the service.”
staff training
1 finding
moderate“some staff were not confident in supporting people who had behaviours which could impact negatively on themselves or others. Staff had e-learning around managing and deescalating behaviours but agreed this was not in sufficient depth”
staff competency
1 finding
moderate“Staff supervisions were regular, every eight weeks but there were no spot checks on staff performance other than for medicine competencies and visual checks during their probationary.”
incident learning
1 finding
moderate“incident management was in place but information not clearly collated too see if additional actions might help reduce the level of incidents.”
record keeping
1 finding
moderate“Gaps in record keeping were identified and clear processes were not in place for every situation.”
infection control
1 finding
moderate“Recent audits identified some significant issues such as exposed wiring, no cleaning schedules and no health and safety checks on the premises.”
end of life care
1 finding
minor“people's care and support plans did not look at people's wishes in relation to treatment they might require or advanced wishes as they got older.”