critical“Medicine competencies had not been carried out for agency staff to ensure they were competent to safely administer medicines to people.”
moderate“Medicines audits were carried out weekly and monthly...however, these were not always effective, as they failed to identify issues of concern we found during our inspection.”
staff competency
1 finding
critical“Agency staff had been covering night shifts as lone workers without having undertaken specialist training.”
governance
1 finding
critical“Systems and processes to monitor, audit and improve the overall quality of the service were not robust enough. This was a breach of Regulation 17.”
care planning
1 finding
moderate“Support plans...were not regularly reviewed or audited and due to the size and content of the document it was at times difficult to find the information you needed.”
record keeping
1 finding
minor“A concern raised by a relative to the manager...on reviewing the complaints overview this had not been logged as per the providers complaints procedure.”
incident learning
1 finding
critical“A medicines error involving an agency staff member in June 2023 identified lessons to be learned...competency assessments for agency staff had not been implemented at the time of our inspection.”
consent capacity
1 finding
minor“MCAs had been completed...however, these were very basic and did not include detailed information relating to how a person was supported to be involved in the decision making process.”
safeguarding
1 finding
moderate“Where safeguarding alerts had been raised with the local authority, we found on 1 occasion the manager had not notified CQC.”
staff training
1 finding
moderate“We found some gaps in refresher training and recording...agency staff training the manager liaised with the agency to ensure training was completed.”