critical“Medicines were not always managed safely and in line with national guidance. Medicine guidelines were not always followed.”
critical“staff who were supporting people with medicines had not all had competency checks completed to ensure they were able to administer medicines safely.”
incident learning
1 finding
moderate“Accidents and incidents were not always used as an opportunity for learning. Incident forms did not always detail action taken to reduce further risks to people.”
staff training
1 finding
critical
“The provider's training matrix evidenced that staff supported people before completing mandatory training, including for example training to support people to transfer safely.”
staff competency
1 finding
moderate“Prior to our inspection not all staff supporting people had competency checks completed to check they knew how best to support people.”
supervision appraisal
1 finding
moderate“the registered manager confirmed that they were in the process of supporting staff through formal supervisions, however not all staff had received supervision.”
safeguarding
1 finding
moderate“Staff had not all received training in safeguarding before working with people.”
governance
1 finding
critical“checks and audits ... failed to identify all the shortfalls highlighted within the inspection.”
complaints handling
1 finding
moderate“we identified all areas of the complaint had not been investigated and responded to by the registered manager.”
end of life care
1 finding
minor“people's end of life wishes and beliefs had not always been recorded.”
record keeping
1 finding
moderate“there were entries written in pencil. There was no system in place to double sign written entries on MAR.”
other
1 finding
critical“The provider had not ensured that all the information and safety checks required before new members of staff started work were in place.”