moderate“Records audited were not always consistent and did not always identify gaps. For example, records did not always contain dates on which they had been reviewed or dates when changes had occurred.”
moderate“There were insufficient quality assurance systems in place to monitor the service effectively.”
record keeping
2 findings
moderate“Records did not always contain dates on which they had been reviewed or dates when changes had occurred. This made it difficult to confirm the frequency or effectiveness of these reviews.”
moderate“improvements were required in respect of all records including staff recruitment files, training, staff meetings and supervision, reviews of peoples care”
staff training
2 findings
moderate“There was a lack of management oversight and training was not always consistent...it was unclear when refresher training was due and how this was monitored and managed.”
moderate“only the registered manager had received training in The Mental Capacity Act 2005 (MCA)... Staff were due to have MCA training on 12 September 2017.”
leadership
1 finding
minor“The provider and registered manager had not completed any surveys or questionnaires to determine how the service was performing.”
care planning
1 finding
moderate“risk assessments were not always personalised or detailed enough to instruct staff how to care for people safely”
medication management
1 finding
moderate“staff had not received training during their employment at the service but had previous experience in administering medicines”
supervision appraisal
1 finding
minor“Staff told us they met regularly to discuss all aspects of the service although the records were not always kept of the discussions.”
staffing levels
1 finding
minor“the registered manger told us that this meant they were working full time to deliver care and this meant that other 'management' tasks were often not completed in a timely way”
consent capacity
1 finding
minor“one staff member told us that she had to remind and prompt a person because they had become forgetful. This may have indicated that a mental capacity assessment was required.”