critical“No care staff member had completed all the training. Some training was overdue for refreshing and some had not been completed at any point.”
minor“staff training was not always up to date. The registered manager told us this was partly due to a move from the local authority providing face-to-face training to online training.”
medication management
1 finding
critical“Systems for managing medicines were unsafe. We looked at 6 people's MAR charts and found four contained gaps. This meant it was unclear whether people had taken their medicines as prescribed.”
record keeping
1 finding
critical
“There was no system in place to pick up these gaps in people's medicines administration as MAR charts were not audited.”
supervision appraisal
1 finding
critical“The registered manager informed us that they had not held supervision with at least eight care staff in the year preceding our inspection.”
governance
1 finding
critical“There were no governance systems in place to identify spot checks were not being completed. Similarly, governance processes had not identified the lack of quality assurance for medicines administration.”
safeguarding
1 finding
critical“The registered manager had not notified CQC about an allegation of abuse which had been reported to the local authority in January 2021, which they were required to do without delay.”
staff competency
1 finding
moderate“There were no medicine administration competency assessments and spot checks were not being completed regularly.”
care planning
1 finding
moderate“There were no risk assessments specific to people's medicines. There was little if any mention about people's medicines and the risks associated with them within risk assessments.”