critical“One staff member told us they had previously administered medicines without the appropriate medication training.”
moderate“Medication administration records showed errors in recording and records for the application of prescribed creams had not been completed.”
staffing levels
1 finding
critical“Adequate checks had not been made to ensure staff were suitable to work with vulnerable people, such as criminal record check and references.”
governance
1 finding
critical“There was no formal governance process in place. The registered manager told us they were completing audits but they did not record them.”
care planning
1 finding
moderate“Care assessments had not considered the full range of people's diverse needs. For example people's oral health care needs had not been assessed or recorded.”
record keeping
1 finding
moderate“The provider had failed to maintain and retain accurate records of the training staff had completed.”
incident learning
1 finding
moderate“The provider did not have an effective system in place for identifying accidents and incidents.”
supervision appraisal
1 finding
moderate“Staff supervision records were not kept and so continuous learning could not be evidenced.”
end of life care
1 finding
minor“The service did not fully assess people's end of life care needs...there was no care plan in place to consider what people would want to happen if they were suddenly taken ill or died.”
complaints handling
1 finding
minor“The processes in place for this were informal, feedback given was not recorded and did not demonstrate how feedback was used to improve the service.”
communication with families
1 finding
minor“Contact and information sharing with people and their relatives was always done via telephone. However some people were unable to use the telephone.”
staff training
1 finding
moderate“Staff training was not always up to date or in line with best practice...unable to demonstrate staff had been trained before they had started supporting people.”
leadership
1 finding
moderate“The registered manager did not demonstrate a good understanding of their legal responsibilities...the registered manager failed to inform CQC in a timely way.”