critical“The folder containing the risk assessments and care plans for one person could not be found. This had not been reported to the management team so that it could be replaced”
minor“Staff recorded what support they provided each day, this was very task based so it was difficult to monitor changes over time.”
minor“The manager recognised the need to ensure the availability of information relating to the way the service was being provided...ensuring that important records...were available in the service's office.”
governance
3 findings
critical“The providers quality assurance systems had not always been carried out effectively to identify areas for improvement. Not all of the registered managers audits had been completed each month.”
moderate
“Some routine management tasks and roles had not been completed recently...there had been a reduction in checks in the period leading up to our inspection, due to staffing issues.”
moderate“Where medicines errors had occurred, the audit and checks in place had not picked this up.”
incident learning
2 findings
critical“Accidents and/incidents were not always analysed in a timely manner to see if any action needed to be taken to prevent a reoccurrence.”
moderate“although the service had learnt from previous errors, there was still room for improvement to ensure people's safety.”
medication management
2 findings
moderate“One person had refused some of their medication on a regular basis, but action had not been taken to follow this up with their GP.”
critical“a person went without pain relief over a four day period. Staff had ordered the medicines but not acted in a timely and coordinated manner when they were not delivered on time.”
care planning
1 finding
critical“one person who was diabetic did not have a diabetes risk assessment, in place. Although the care plan stated that the person was diabetic it did not include any information about what support the person needed”
infection control
1 finding
moderate“the guidance for testing staff (to test for five days) had not been followed when a member of staff had tested positive for Covid-19.”
staffing levels
1 finding
moderate“staffing levels were variable. One relative said, 'I think the staffing levels are not good. They do use agency staff quite a lot to cover.'”
consent capacity
1 finding
minor“in the isolated situations where people were starting to present with variable capacity, there was scope for a more formal review and recording of their capacity to consent to care.”
supervision appraisal
1 finding
minor“there were good measures in place to provide supervision and team meetings and though these had not taken place with the usual frequency over the summer”