critical“staff were signing medication records where covert medication was being given by the family without witnessing the medication being placed in food”
moderate“care plans and daily record notes were not always clear, and we could not determine whether staff had prompted or administered people's medicines. MAR had been completed however this had not been done in line with best practice.”
care planning
2 findings
moderate“People's support plans did not include information on how people would be supported to meet their assessed needs”
minor“some care plans did not always contain detailed guidance for all aspects of people's care needs, including managing any associated risks; for example, catheter care.”
record keeping
2 findings
moderate“Care records for people did not contain information on people's preferences and choices fully or clear instructions on how staff would meet people's needs”
minor“We hadn't realised how much we had fallen behind in regards to what is required to evidence good care.”
governance
2 findings
critical“provider had failed to implement a robust quality monitoring system that operated effectively to ensure compliance with regulatory requirements”
moderate“the provider will need to demonstrate that their quality assurance and safety processes are robust enough to sustain good quality care delivery over time and independently of external support”
person centred care
2 findings
moderate“No evidence was available to show that the content of the support plans had been agreed with the person who used the service or those acting on their behalf”
minor“With the exception of sexuality needs, people's equality and diversity needs were identified and recorded in care plans. The provider told us they would update care plan documentation to include people's sexuality needs.”
consent capacity
2 findings
moderate“there had been no training on the Mental Capacity Act 2005 for staff...none of the staff were able to demonstrate an understanding of the requirements”
minor“people had not signed their care plans to show they consented to their care and support.”
safeguarding
1 finding
critical“staff were concerned for a person's wellbeing in terms of a relative's interventions. No attempt had been made by staff to discuss this with management”
staffing levels
1 finding
critical“a 'staff member' was working for the service that had not been recruited at all”
staff training
1 finding
critical“staff had not received specific training relating to catheter care...instruction had been given by other members of staff who were not trained to deliver this specific training”
supervision appraisal
1 finding
moderate“It is hoped that supervisions will be held four times a year but none have been done as of yet...appraisals had not been completed at this time”
staff competency
1 finding
moderate“registered manager could not evidence that staff were assessed following the training to ensure they were competent or to see if the training had been effective”
leadership
1 finding
moderate“this key question will remain as Requires Improvement, so the provider can evidence over time that they can independently and robustly monitor and manage the service as it expands”