critical“when we checked the physical stock balance of medicines these did not correspond with what had been administered. Records did not show what the current stock balance should be.”
care planning
1 finding
critical“Risk assessments and care plans were not always in place to guide staff on how to support people with their medical needs. This included a lack of guidance on the support people needed with epilepsy and diabetes.”
governance
1 finding
critical“medicine audits did not identify the shortfalls we found in relation to the safe management of peoples medicines.”
record keeping
1 finding
moderate“Audits of care records and risk assessments did not identify they were not always reflective of people's current needs or person centred to guide staff.”
incident learning
1 finding
moderate“not all accident and incidents records were reviewed by the senior management team to review the details and to assess if any further action was required to reduce known risks.”
staff training
1 finding
moderate“some staff had not received training in relation to some of the medical conditions of the people they supported. This included, epilepsy, diabetes, and catheter care.”
staffing levels
1 finding
moderate“The guidance in place for staff to follow in the event of a fire did not consider the reduced staffing levels at night or people's individual support needs.”
person centred care
1 finding
moderate“the provider could not evidence how people were supported to understand their right to choose a different provider without this affecting their tenancy.”