critical“Effective arrangements were not in place to ensure medication practices were safe and risk was minimised. This demonstrated a breach of Regulation 12.”
governance
1 finding
critical“The provider had not ensured effective processes were in place to assess, monitor and improve the quality and safety of the service. Breach of Regulation 17.”
care planning
1 finding
moderate“Care plans did not always reflect people's needs. The delivery of care was inconsistent and did not always match the aims of care plans.”
staff competency
1 finding
moderate“Agency and new staff did not always have the skills and information to meet people's needs.”
staff training
1 finding
moderate“The provider had not ensured all staff had access to the necessary support to develop their skills, in particular for specialist medicine administration.”
staffing levels
1 finding
moderate“Most staff told us there were not enough staff to meet people's needs. A member of staff told us, 'We don't have the time or staff to do what we would like to.'”
person centred care
1 finding
moderate“The staffing is totally not centred on the person's needs. Because of lack of stimulus and suitable activities, [Person] spends a great deal of time in their bedroom.”
communication with families
1 finding
moderate“Some relatives told us they had heard of mistakes around medicines from a social worker, rather than from the provider.”
complaints handling
1 finding
moderate“Most of the concerns raised during the inspection had not been recorded centrally and so the complaints process was not being used as a positive tool to drive improvements.”
consent capacity
1 finding
moderate“Not all staff had an understanding of capacity and how to work within the principles of the MCA. Systems did not effectively support people to communicate their decisions.”
incident learning
1 finding
moderate“We found examples where incidents were not reported promptly or fully, and the manager did not have full oversight of what was happening across the service.”
leadership
1 finding
moderate“There was no registered manager at the service... the manager covered a wide geographical area and was overstretched.”
record keeping
1 finding
moderate“We found a care plan which had not been amended and held out of date, unsafe information about support with buccal medicines, despite an audit stating the plans had been updated.”