critical“We found occurrences where the service had not identified or reported potential safeguarding concerns to the local safeguarding authority as required.”
medication management
1 finding
critical“Written protocols for when needed medicines were not always in place, controlled drugs records were not fully completed at one setting and stock control records did not balance for one medicine at another setting.”
governance
1 finding
moderate“Quality and safety audits had not been kept-up during COVID-19.”
staff competency
1 finding
moderate“We received feedback that some agency staff were not appropriately skilled or demonstrate the right values to meet people's needs and keep them safe.”
staffing levels
1 finding
critical“At one setting the service had not considered staffing levels at night to safely evacuate people in the event of an emergency.”
care planning
1 finding
moderate“Risk assessments were not consistently documented in response to people's needs. For example, one person's risk of pressure ulcers was not recorded.”
record keeping
1 finding
moderate“Management and people's care records were sometimes incomplete or lacked enough written information about their support needs and risk.”
incident learning
1 finding
moderate“Incident reports were not always fully completed to confirm the manager had reviewed the incident or acted to mitigate risk.”
consent capacity
1 finding
moderate“documentation about one person's mental capacity to consent contradicted information within their deprivation of liberty order.”
staff training
1 finding
minor“Training in physical interventions and diabetes awareness had lapsed for some staff”
infection control
1 finding
minor“at a third setting cleaning products were not locked away at all.”
end of life care
1 finding
minor“People's care plans did not include end of life preferences.”
cultural competency
1 finding
minor“protected characteristics such as gender identify and sexuality were not captured.”
leadership
1 finding
moderate“We received mixed positive and negative feedback from people, their relatives and staff about the management of the service.”