critical“One person's care plan stated they were at risk of choking, however there was no guidance in place for staff to inform them how to respond if this person exhibited symptoms of choking.”
critical“Risks were not assessed, monitored or managed appropriately. There was no written guidance or control measures in place to mitigate risks.”
moderate“Care plans did not include individual likes, dislikes and preferences... no evidence to demonstrate people's care was personalised.”
medication management
3 findings
critical“There was no guidance in place for people who were prescribed 'as and when required' medicines and staff did not record the dose administered.”
critical
“We found missing signatures on the 3 medicine administration records (MAR) viewed. This meant people did not always receive their prescribed medication.”
critical“MAR were handwritten and were not completed in line with best practice, for example the strength, dose or route of medicines had not been recorded for 3 people.”
governance
2 findings
critical“The provider's auditing processes were ineffective and did not identify any of the shortfalls found during our inspection. Care plan audits did not identify the lack of information recorded in 9 different care plans.”
critical“There were no systems in place to audit any aspect of the service, this meant there was no evidence of learning, reflective practice or service improvement.”
incident learning
2 findings
critical“There was a lack of evidence to show the provider had processes in place to learn from events. The issues identified at the previous inspection were still not addressed at this inspection.”
critical“There were no statutory notifications submitted in the last 12 months to inform us of significant events that happened at the service.”
leadership
2 findings
moderate“One staff member said, 'The [registered] manager is rough with us. The management style is very outdated, they don't listen to staff'.”
critical“The provider who worked as the registered manager did not fully understand their responsibilities of their registration with us.”
record keeping
2 findings
moderate“Staff used a communication portal to share concerns about people's health and wellbeing, however we saw no evidence that the provider took any actions to follow up on the concerns.”
critical“We found 2 recruitment files of staff employed that did not include references or full employment history. One person employed did not have a completed criminal record check.”
person centred care
2 findings
moderate“One person requested to be supported by female staff only, but this was not recorded in their care plan. We saw that on one occasion this person's request was not accommodated.”
moderate“Care plans did not consistently include people's preferences, choices or social history. This meant people or their relatives were not fully involved to inform care planning.”
supervision appraisal
2 findings
minor“Some staff felt supervisions were helpful and a safe space to discuss any concerns. Others felt they were not well supported by the manager and did not feel comfortable raising issues.”
moderate“Staff supervision and support was not consistent... supervision records we saw were a short checklist not detailing specific discussion or progress.”
staffing levels
1 finding
critical“We found 8 recruitment files of staff employed at the service that did not include checks with the Barring Service. This meant people were at risk of receiving care from unsuitable staff.”
consent capacity
1 finding
critical“People had mental capacity assessments but they were not completed in line with the Mental Capacity Act Code of Practice. There were no best interest decisions in place for people who lacked capacity.”
safeguarding
1 finding
critical“There were no systems in place to analyse accidents or incidents... people were at risk of harm due to no analysis or identification of trends.”
staff competency
1 finding
moderate“The provider could not evidence staff competency checks had been undertaken to ensure staff remained safe to administer medicines.”
staff training
1 finding
moderate“Not all staff had received infection prevention control (IPC) training. This posed a risk in relation to managing and minimising the risk of infection.”
infection control
1 finding
minor“The policy did not refer to procedures in relation to COVID-19. This meant there was a risk that procedures in relation to COVID-19 may not have been embedded.”