critical“Some medicines administration record (MAR) charts were missing information, some had not been completed correctly and one week their MAR chart had not been completed and was blank.”
critical“the person's medicines were not always administered in line with NICE (The National Institute for Health and Care Excellence) guidelines for medicines management”
safeguarding
2 findings
critical“Some staff lacked sufficient knowledge and understanding about the types of abuse people could experience, how to recognise signs of abuse and how to report abuse to external organisations.”
critical“The provider had not always reported safeguarding incidents to the local authority.”
staff training
1 finding
critical“Some of the staff used to provide the person with care when their usual care workers were not available had not received training to work with epilepsy, learning disabilities, behaviours that some people may find distressing and PEG”
staff competency
1 finding
critical“A carer came and [name of person] had a seizure and I saw on the camera that the member of staff tried to lift [name of person] up during the tonic seizure instead of leaving [name of person] until the seizure had passed”
care planning
1 finding
critical“The person's risk assessments were not always completed and their risk assessments and care plan did not always contain detailed and specific information for staff to manage risks safely.”
governance
1 finding
critical“The provider had not always carried out audits and audits carried out had not identified the issues we found during the inspection.”
record keeping
1 finding
moderate“The provider had not recorded any information about COVID-19 testing for staff, including the results of staff Lateral Flow Tests.”
person centred care
1 finding
moderate“The person's daily support plan was task focused and did not contain any information for staff about how the person wanted tasks carried out or how they wanted their personal care done.”
staffing levels
1 finding
moderate“The provider had not always gathered sufficient information about the work history and previous employers of new staff and had not always obtained references for new staff from one of their previous employers”
infection control
1 finding
moderate“the provider had not carried out individual COVID-19 risk assessments for the person and staff. This increased the potential risk of harm to the person and the staff from COVID-19”
leadership
1 finding
moderate“The registered manager and the operations manager were not engaged with and did not participate in any learning and development or support networks for registered managers and providers.”