critical“People's medical conditions were not fully assessed and records did not include the level of detail needed to ensure safe care.”
moderate“Clear and complete records were not always in place relating to the management of the service or to support staff to provide safe and person-centred care.”
minor“we identified that the policy was not dated so we could not be sure the policy had been updated to reflect changes in current best practice”
critical“The date, any allergies the person had and details of people's doctor was frequently not recorded on MARs.”
governance
4 findings
critical
“Audits in place were not sufficient or robust enough to highlight all shortfalls identified on the inspection.”
critical“The provider did not have a robust and transparent system of audits to evidence how they checked and made sure the service was safe.”
minor“the action taken had not been clearly recorded. We discussed this with the manager who told us they would ensure all audits included a section to record actions taken”
critical“Systems and processes in place to assess, monitor and drive improvement in the quality and safety of the service provided were not always effective.”
medication management
3 findings
critical“Some people's medication on their care records did not match the MAR charts, some records were unclear, and signatures were missing.”
critical“Care plans, risk assessments and guidance for medicines prescribed when required did not contain enough information for staff to administer these consistently and safely.”
critical“Staff did not appropriately record support provided for people to take prescribed medicines. Management checks were not robust enough to identify and address this.”
care planning
2 findings
moderate“More detail was needed in the care plans to ensure people's needs and preferences were fully understood and recorded.”
moderate“Care plans and risk assessments did not always contain enough information to support staff to provide safe and consistent care.”
consent capacity
2 findings
moderate“Best interest decisions had been made however these were not decision specific and the records did not evidence who was involved in the decision making.”
moderate“Staff did not complete or document mental capacity assessments or best interest decisions around consent to care.”
staff training
2 findings
moderate“The provider did not have a robust training plan or a clear way to monitor and make sure staff had the training they needed to provide safe high-quality care.”
moderate“Four members of staff needed to update their medication management training, three needed to update safeguarding training.”
safeguarding
2 findings
minor“The provider needed to update their safeguarding policy and procedure to ensure it contained detailed information about how safeguarding concerns would be managed.”
moderate“Safeguarding training material had not been updated to reflect changes introduced by the Care Act 2014 and therefore was not reflective of current legislation.”
incident learning
1 finding
critical“Staff told us people had accidents however these had not been recorded, people's safety had not been managed and lessons had not been learnt.”
missed or late visits
1 finding
moderate“There was not a formalised system in place to ensure the monitoring of late or missed calls, the quality of the care or standard of care records.”
supervision appraisal
1 finding
minor“Regular staff meetings had not always taken place but plans were in place to improve this... these had previously only been planned to take place once a year”
staff competency
1 finding
moderate“There was no evidence that robust medication competency checks were completed.”