moderate“Staff records did not contain all the necessary documents and evidence to support robust recruitment practices.”
minor“Some of this information was spread throughout care plans so was not always easy to find.”
minor“There was no care plan for food and drink in their records so it was unclear how meals were chosen and whether they were suitable for the person in question.”
moderate“a medicine have not been supplied from June to July 2016 and there was no reason recorded as to why this was.”
medication management
3 findings
moderate
“Records did not always show the amount, for example in milligrams, of medicines to be given so staff might not be aware if a mistake had been made.”
moderate“There were no PRN (as required) medicines protocols in place so it was not clear when and why these medicines should be administered.”
minor“there was no information in place for staff on the purpose of specific medications and their side effects.”
staff training
2 findings
critical“Only 24% staff had completed training in moving and handling people, 34% in basic first aid, 31% in food hygiene, and 35% in health and safety.”
moderate“staff needed training on how to assess people's capacity to make decisions about how they lived their lives.”
governance
2 findings
critical“Systems and processes had not been sufficiently developed to ensure the effective assessment and monitoring of the service. This is a breach of regulation 17.”
moderate“a small number of records where staff had not attended at the agreed time...had not been picked up in the audit process.”
staff competency
2 findings
moderate“Satisfactory evidence of conduct in previous employment within the field of health and social care had not been requested. The provider had relied on character references.”
critical“for one staff member whose reference stated they had been subject to disciplinary procedures...there was no evidence that further checks had been carried out.”
care planning
2 findings
minor“General risk assessments for people's premises were not routinely in place.”
moderate“risk assessments for managing behaviour that challenged the service or for preventing pressure sores. Staff did not have the information on how to keep people safe.”
staffing levels
1 finding
critical“There were not always sufficient staff employed to meet people's assessed needs and provide their agreed packages of care.”
leadership
1 finding
moderate“In response to staff shortages the manager was providing personal care and support to people. This restricted the time available to them to monitor the quality and safety of the service.”
person centred care
1 finding
minor“The scope and range of questions asked was limited. This restricted opportunities for people to fully comment upon the quality and experience of the care provided.”
consent capacity
1 finding
moderate“there were no formal procedures in place to assess people's mental capacity.”
supervision appraisal
1 finding
minor“Staff told us they received supervision and there was some evidence of these sessions, though this was infrequent.”
safeguarding
1 finding
moderate“in the safeguarding adults policy, this did not include information as to what different types of abuse were.”
complaints handling
1 finding
minor“no response had been provided to the complainant setting out the results of the investigation.”