moderate“Areas for improvement were found which had not been identified in the home's medicine audits. Hand-written entries were not always signed by two staff.”
moderate“Protocols to guide staff about when to administer medicines given on an 'as required' (PRN) basis were not always in place.”
moderate“Staff had not signed the MAR charts for two people on a few occasions when medicines were administered.”
record keeping
3 findings
minor“There was a lack of evidence about the progress they were making in working towards these [goals and intended outcomes].”
moderate
“There were no daily report entries on 11, 12 and 15 November 2015 for one person. Activity planners were not up to date, keyworker notes on two occasions stated that daily reports had entries missing.”
minor“Best interest decisions reached were not always reviewed to ensure the decisions remained accurate. Action plans did not provide an audit trail of the actions.”
governance
2 findings
critical“Medicines audits did not identify all areas for improvement. Where shortfalls were found, action was not taken.”
moderate“Medicine management audits had not identified staff were not signing MAR charts following the administration of some medicines and that staff were not following the cleaning schedules.”
staffing levels
2 findings
moderate“Records showed the actual staffing numbers were between three or five on duty, which meant people could not always go out into the community.”
critical“Insufficient staff were deployed to meet people's needs. Staff said the service was often short staffed. The registered manager said there had been a 27 percent turnover of staff.”
person centred care
2 findings
moderate“Records confirmed people were not receiving their funded one-to-one support time to access the community consistently.”
minor“Some care plans were not fully person centred because their ability to manage aspect of their care was not included.”
consent capacity
2 findings
moderate“The next of kin giving consent did not have power of attorney. This meant best interest decisions to share information was not made within the principles of the MCA 2005.”
minor“For one person the agreement was signed in 2014 and was not reviewed to ensure the person continued to have capacity to take this decision.”
care planning
2 findings
moderate“Care plans were not always updated following reviews; they were duplicated and inconsistent with each other.”
moderate“As people's needs increased care plans were not updated with supplementary information instead an additional care plan was introduced.”
leadership
1 finding
critical“There were shortfalls in the managerial oversight of the service, including overseeing how staff planned their time.”
staff training
1 finding
moderate“77.8 percent had attended safeguarding of vulnerable adults training... Members of staff had not attended all mandatory training set by the provider.”