critical“The provider's quality assurance systems had not identified these shortfalls so these could be rectified appropriately.”
moderate“not all systems were embedded. The registered manager was still in the process of developing some of the audit tools. While there were suitable templates in place to record if staff recruitment processes had been completed, they were not yet used.”
moderate“a risk assessment was not written to reflect the safety measures taken when a reference could not be obtained. The provider's quality assurance system had not identified this shortfall.”
staffing levels
2 findings
critical“the provider requested, but had not always waited until they received, satisfactory references before employing staff. One staff records contained no employment or any other references”
minor
“one relative told us that whilst usually the staff called as scheduled they had experienced an occasional lapse in service. 'On one occasion one staff didn't turn up and once one was an hour late.'”
record keeping
2 findings
moderate“errors in the completion of the medicine administration records (MARs) had not been identified and investigated by the provider”
minor“one person's documents were not consistent in stating when a medicine should be taken before or after food. This was because one support plan stated after a meal rather than before a meal.”
medication management
1 finding
moderate“there was an individual medicine (to help people sleep)...recorded as administered by staff at, 'Breakfast' between 1 to 17 August...not in line with the recorded prescribed dosage”
consent capacity
1 finding
minor“a third file contained the person's written consent for their relative to make decisions for them when it stated...the person did not have the capacity to make their own decisions. This was not in line with the MCA.”