moderate“people's risk assessments lacked information for staff on how to mitigate risks to provide safe care”
critical“We were only able to view one person's care plan as the service had not developed care plans for other people.”
medication management
2 findings
critical“one person's MAR charts for the month of January did not record what medicines had been administered in the week commencing 22 January 2018”
critical“MAR charts were not appropriately completed. Some MAR charts did not mention the time when staff were required to give medicines.”
supervision appraisal
2 findings
moderate“two staff had received only one supervision in the last year”
moderate“Staff had not been receiving regular supervision, the registered manager confirmed they had not formally supervised their staff.”
governance
2 findings
critical“The registered manager carried out quarterly telephone monitoring calls but did not maintain any records of these calls. They had not carried out any spot checks”
critical“The service had not carried out any audits of people's risk assessments, care plans and staff recruitment documents.”
record keeping
2 findings
moderate“some people's daily care notes had minimal information and exactly same description of how they had been supported across weeks”
critical“The service lacked efficient systems and processes to assess, monitor and improve the quality and safety of the care delivery.”
person centred care
2 findings
minor“The care plans were detailed and included information on people's background but did not include their likes and dislikes.”
moderate“'Care task plans' were task oriented, and the care plans were not always completed and lacked personalised information.”
staff training
1 finding
moderate“Staff did not receive health specific training such as dementia, diabetes, stroke to support people with health needs.”
staff competency
1 finding
critical“Not all staff files had recent DBS checks and still had criminal record checks from their previous employer that had passed the three months period.”
consent capacity
1 finding
critical“People's care plans did not make reference to people's capacity and did not include information on how and when to support people to make decisions.”
incident learning
1 finding
minor“accident and incident records did not always record lessons learnt. The provider told us in the future they would include lessons learnt in the form for a better audit trail”