moderate“We found environmental audits required further development...broken wall mirror, toilet seats, dirty bath-mats and a window dressing that needed replacement. These had not been identified in audits.”
critical“A lack of systems and processes to review medicines practices meant the concerns outlined in the safe section of this report had not been identified by the provider.”
critical“Medicines fridge temperatures were consistently warmer than the temperatures set out... identified over several months however, action had not been taken to address this.”
medication management
3 findings
critical“Medicines disposal did not follow safe processes. Medicines which were no longer in use were stored in an unlocked cupboard in an unlocked room.”
critical
“Some nights there was no staff on shift trained to give medicines on site. One person told us, 'There is no-one to give me pain relief in the night.'”
moderate“Staff lacked guidance to direct them when 'as required' medicines should be given... This meant people may have received medicines inappropriately.”
care planning
2 findings
moderate“Positive behaviour support plans required further development to ensure people received safe, effective support.”
moderate“One person who was diabetic did not have symptoms listed in the care plan for staff to look out for if blood sugars were raised.”
record keeping
2 findings
minor“care records required further development to ensure all information was included in people's care plans. Care plans were under review at the time of our inspection.”
moderate“Accurate and up to date records had not been kept... a sentence in their care plan stated 'To discover what events/activities [name] enjoys'.”
incident learning
2 findings
moderate“Incidents and near misses were recorded, however the registered manager had not reviewed them, or shared lessons learned.”
moderate“We identified 5 incident forms, some of which were 5 months old, which had not been reviewed by the registered manager or their deputy.”
infection control
2 findings
minor“An internal infection prevention and control (IPC) audit was overdue.”
minor“Bins in toilets and bathrooms needed to be replaced with pedal bins, additional COVID-19 and IPC related signage was required.”
staff competency
1 finding
moderate“Staff had not regularly received checks on their competency to give medicines. This meant the provider may not have identified staff who needed additional training.”
safeguarding
1 finding
critical“Appropriate legal authorisations were not always in place to deprive a person of their liberty. 2 people had no mental capacity assessments for sensor mats.”
staff training
1 finding
critical“There were gaps in some recruitment and induction records. There was not always a full employment history recorded, application forms and interview records for all staff.”
staffing levels
1 finding
minor“Agency staff were used to cover staff shortfalls.”