moderate“One person took their medicines with food and this was not referenced in their care plan. This meant staff did not have access to approved information about how to do this safely.”
critical“Discrepancies between the medicines administration records (MAR) and the instructions on the medicine for 3 people.”
critical“People who received 'as and when required' medication did not have guidance to support staff to administer these.”
staff competency
2 findings
critical“4 of these staff had not been directly observed giving medicines as part of their recorded competency assessment. An additional member of staff had not had any competency assessments carried out and was lone working.”
critical
“Staff supporting people with their mobility had undertaken online training but had not had their practical competency assessed.”
care planning
2 findings
minor“The review and update of 1 person's risk assessment had not identified it continued to reflect out of date guidance about visitors to their home.”
minor“People's oral care needs had not been clearly assessed and there was no information available in the care plan or handovers.”
consent capacity
2 findings
critical“Where a senior member of the team had determined the person could not consent to their care staff had signed consent on their behalf.”
critical“Where care provided included restrictions...it was not clear that these decisions were made lawfully.”
governance
2 findings
critical“An allegation of abuse had not been shared and as a result it was not reflected on the safeguarding oversight tool...a statutory notification was not submitted to the CQC.”
critical“CQC had not been informed about a serious injury in 2022.”
record keeping
1 finding
moderate“Risks were not all appropriately assessed and mitigated...it was not possible to review the management of these risks because they were not recorded.”
staffing levels
1 finding
moderate“Recruitment processes were in place but these had not been operated effectively...unexplained gaps in all 4 recruitment records we reviewed.”
safeguarding
1 finding
critical“An allegation of abuse had not been shared and as a result it was not reflected on the safeguarding oversight tool.”
incident learning
1 finding
moderate“Systems to ensure appropriate actions following accidents and injuries had not been effective in ensuring appropriate notifications were made.”