critical“medicine administration records were not completed correctly as per current guidance and 'as required' medicines had not been recorded correctly.”
critical“the medibox was recorded on medicines administration records (MARs) as a single entry when in fact a number of medicines had been administered”
critical“At the last inspection the provider did not have proper and safe management of medicines procedures in place. That meant people were in danger of not receiving their medicines at all, or at the incorrect time or at the incorrect dosage.”
staff training
2 findings
critical“Moving and handling records showed that only three staff had up to date training. safeguarding, medicines and infection control training were also out of date.”
moderate
“At the last inspection we found the provider had not given staff appropriate or sufficient training, supervision or appraisal.”
supervision appraisal
2 findings
critical“One member of care staff reported they had never had an appraisal and another member of care staff said, "I last had it at the beginning of January 2014."”
moderate“At the last inspection we found the provider had not given staff appropriate or sufficient training, supervision or appraisal. This meant staff had not been given the opportunity to further develop their skills.”
governance
2 findings
critical“Overall, audits and checks, including those by the manager and the provider, were not robust.”
moderate“At the last inspection we found the provider did not have robust quality assurance systems in place, including monitoring of accidents and incidents and regular audits.”
care planning
2 findings
moderate“one person's care records stated they needed to be supported with a shower. The records did not explain how staff would do this or how the person preferred to be showered.”
moderate“A small number of people's care plans had not been reviewed recently, including one since May 2014.”
record keeping
2 findings
minor“Staff did not have any written information [at handover], which meant that there was a possibility of relevant and important information being missed by accident.”
minor“We saw that where some training had been completed, no certificates were produced by the training agent. The registered manager was looking into this.”
incident learning
1 finding
moderate“the manager told us that they currently did not keep an accident and incident log to monitor any trends forming.”