critical“protocols were not always in place to guide staff when to administer people's 'when required' medicines. This meant people were at risk of not receiving their medication safely”
moderate“1 person's record stated 1 medicine was only to be taken 'as and when required', but this was being taken 3 times each day. Another person's records contained conflicting information about what medicines the person needed to take.”
governance
2 findings
critical“Medicines audits detailed protocols were in place to guide staff when to administer 'when required' medicines...During the inspection these were not always in place”
critical“The provider's auditing of care settings for quality and safety was still not fully effective. Issues we found during our inspection had not been identified by the provider's own systems.”
care planning
2 findings
moderate“Some care plans and risk assessments were detailed and accurate, others lacked guidance and information to ensure care was delivered safely.”
critical“Information and guidance in care plans was inconsistent. For example, 1 person had a health need and staff were required to seek medical assistance at specific times. The persons care plan and risk assessment contained different information regarding this.”
record keeping
2 findings
moderate“Records contained contradictory information. For example, one person's risk assessment stated that the local authority managed their finances, although another document stated it was the person's parents.”
critical“Their care plan stated they 'had no recorded falls for 6 months'. Other records indicated they had fallen 7 days prior to the inspection.”
communication with families
2 findings
moderate“Our biggest concern is there is no communication. We ask for meetings to discuss issues and the management say please contact us and we will do better but it just does not happen”
minor“One staff member told us, 'We haven't had a team meeting in 6 months.'”
safeguarding
1 finding
critical“The provider did not have effective systems and processes in place to safeguard people from the risk of financial abuse.”
consent capacity
1 finding
critical“People's mental capacity was not always assessed in line with the MCA and the provider's own policies.”
incident learning
1 finding
moderate“There was a process for reporting and recording accidents and incidents and these were analysed by the provider. This hadn't always been effective in ensuring any concerns were addressed and learning shared amongst the team.”
staff competency
1 finding
moderate“We reviewed the training records of agency staff and not all of them had received training in dysphagia, this is where people experience difficulties in swallowing.”
leadership
1 finding
moderate“One staff member told us, 'It's difficult because we seem to be in and out with managers all the time. Honestly, no I do not feel that well supported.'”