critical“one person had a care plan that stated they were taking two medicines when their MAR chart showed they were taking six medicines.”
critical“systems were not in place to monitor people received their medicines as the prescriber had intended... there were insufficient systems in place to manage the administration and or prompting of people's medicines safely.”
care planning
2 findings
critical“One person had specific healthcare needs and had no care plan in place to support this.”
moderate“People's care plans did not explain and guide staff about how to meet people's needs in a safe way... a lack of personalised guidance for staff to follow.”
record keeping
2 findings
moderate“audits of the care records had failed to identify where gaps in recording were.”
moderate“people's daily notes were not being audited. This meant that any shortfalls in peoples care were not being identified and acted upon in a timely way.”
governance
2 findings
moderate“audits undertaken were 'tick box' and did not include any actions. There was no evidence of issues being identified and addressed.”
critical“There were insufficient systems in place to monitor the quality of the care and service provided. Audits were not taking place in relation to people's care records.”
consent capacity
2 findings
critical“service was supporting a person who was living with dementia...their capacity to consent to their care had not been considered in line with the legislation.”
minor“The service had not sought consent on people's behalf, to share information or raise concerns with health and social care professionals.”
staff training
2 findings
moderate“staff told us that this platform for learning did not help them understand any changes to care practices and give them the skills and knowledge they needed.”
moderate“Staff were supporting people who had diabetes and mental health needs and they had not received training in their induction in these areas.”
person centred care
1 finding
moderate“care plans were not always focussed on how staff should support the person to mitigate the risks to their health and wellbeing.”
safeguarding
1 finding
critical“only one was aware of the local authority safeguarding team... The manager should not have spoken with the relative [about money missing allegation].”
staff competency
1 finding
moderate“Some members of staff did not shadow staff before they started to provide care independently... one member of staff had not received a spot check and had been working since September 2016.”
incident learning
1 finding
critical“We were told of a safeguarding event which involved social services but we were not informed of this [by the registered manager to CQC].”