critical“People prescribed as required medicines (PRN) did not have protocols in place to ensure medicines were given consistently by staff.”
critical“Records did not always contain adequate information for staff about short term medicines...Staff had not been provided with guidance to inform them of the health concern.”
critical“A person had not had access to their prescribed regular pain medicine for thirteen days and this had not been identified by staff and as a result this was not acted on promptly.”
moderate“People's medication administration records (MAR) did not always show that an 'as required' medicine (PRN) was given in accordance with their prescribed guidance.”
care planning
4 findings
minor
“Some risk plans which were generic. The provider acknowledged this system was in the process of being embedded within the service.”
moderate“Care and risk records lack personalised detail and did not always contain guidance for staff to help ensure people remained safe.”
moderate“Risk assessments for people were generic and not personalised. They lacked detail and personalised information relating to specific health care needs.”
moderate“they did not contain enough information about preferences and life history to provide an insight into them as an individual.”
governance
3 findings
moderate“Audits were in place, but these did not always identify areas for improvement...medicine audits were completed but had not identified shortfalls about the lack of person-centred PRN information.”
critical“medicine audits did not always reflect what the records had noted. The audits completed in December 2020 and January 2020... The audit result was marked 'yes', however, this was not evident on MAR sheets reviewed.”
critical“The provider did not have effective quality systems in place or have effective oversight of the service.”
consent capacity
2 findings
critical“Capacity assessments were not always completed with people to detail their capacity to consent to specific decisions relating to their care.”
critical“The provider was unaware if some people making decisions on people's behalves had Lasting Power of Attorneys for Health and Welfare.”
safeguarding
1 finding
critical“two incidents that had not been managed safely. Not all had been identified or reported in accordance with the providers policy or the providers statutory obligation to report allegations of abuse”
record keeping
1 finding
moderate“This failure to identify ongoing poor record keeping increased the potential impact poor practice could have on the person.”
staff competency
1 finding
critical“A staff member had been employed ahead of receipt of DBS certification. This placed people at risk of harm as the character and suitability of staff had not been fully considered.”
supervision appraisal
1 finding
moderate“Management records had shown that a staff member required feedback on their conduct. There was no evidence that this had been completed and this comment was repeated through several meeting minutes.”
leadership
1 finding
moderate“The nominated individual had day to day management of the service from mid-December 2020 following the Registered Manager resignation.”
incident learning
1 finding
critical“The provider had not demonstrated that they had a robust system in place to ensure that statutory notifications to CQC had been completed or demonstrate lessons learnt as a result.”
end of life care
1 finding
moderate“the service was providing end of life care to three people. Care records showed all three people, and/or their relatives had not been consulted about their preferences and they did not have advance care planning in place”
person centred care
1 finding
moderate“Peoples history, their background, aspirations, goals, likes and dislikes were not always included. Examples of where this was included, lacked detail.”