critical“A third person had fluctuating mobility and required staff to use a hoist...their moving and handling risk assessment did not contain any guidance for staff detailing the steps staff should follow to safely hoist them.”
moderate“The assessment did not consider nutrition or hydration, or people's skin integrity to help demonstrate that assessments had been conducted holistically.”
moderate“People's care plans did not identify when they received support from other healthcare services, or whether support from healthcare professionals had been considered.”
medication management
2 findings
critical“We found six gaps on one person's MAR from August 2018 and five gaps on another, which meant we were unable to establish whether the two people had received their medicines as prescribed.”
critical“One person's MAR contained inaccurate information regarding the maximum safe dose of an 'as required' pain relieving medicine.”
staff training
2 findings
critical“The registered manager was unable to explain how staff were able to effectively complete training in such a wide number of areas on a single day.”
critical“Records also showed that the same staff member was working on 12 May 2018 so they could not have attended training on that date.”
governance
2 findings
critical“The provider's systems for monitoring the quality and safety of the service were ineffective in consistently identifying issues or driving improvements.”
moderate“In total we found areas of concern in five people's care plans which had not been identified by the provider during their auditing process.”
leadership
1 finding
moderate“They were not aware of all of the different events which they were required to notify CQC about...they were unaware of the frequency at which a hoist should be serviced.”