critical“a few people's medicines had been 'secondary dispensed' into multi-compartment aids, which had no pharmacy label... staff could not be assured of what they were administering”
moderate“MARs did not always list the medication name and / or dosage to be given... this was not in line with safe administration or the provider's own medication policy.”
care planning
2 findings
moderate“some people's individual needs had no plan of care in place for staff to refer to.”
moderate“Whilst risks were listed and assessed as low, medium or high, there was no further information to inform staff about the actions they should take to reduce risks of harm or injury.”
staff training
1 finding
critical“Moving and handling training did not consistently give staff the skills or knowledge they needed to keep people safe. One staff member told us they had physically lifted a person, using an underarm lift”
staff competency
1 finding
moderate“one member of staff told us they had completed an online first aid course but when we asked what action they would take for a scald they described action that could increase skin damage.”
governance
1 finding
critical“This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008... Some quality checks were in place and were recorded. However, these had not identified issues”
incident learning
1 finding
moderate“one fall we were told about was not recorded which meant the opportunity to learn lessons and mitigate reoccurrence was missed.”
end of life care
1 finding
moderate“End of life care and palliative care planning was not in place... there was no palliative care plan to inform staff of this person's wishes.”
communication with families
1 finding
minor“their plan of care did not inform staff how best to achieve effective communication given this person's visual and hearing impairments.”
infection control
1 finding
moderate“Staff had not received training, or competency assessments, in Coronavirus or 'donning and doffing' PPE.”
record keeping
1 finding
moderate“Some employment records had gaps in information... 'Care Worker Agreements' were not always dated or signed and it was therefore unclear when some staff had commenced their employment.”
supervision appraisal
1 finding
moderate“Competency assessment records were basic and did not detail tasks observed or what knowledge had been checked.”