critical“medicines information within the person's care plan was not always updated when there were changes in their medicines...This meant there was not an accurate and up to date record of the person's medicines.”
critical“Medicines information in this person's care plan did not match the medicines that were highlighted on their MAR chart.”
staff competency
2 findings
moderate“the staff member had completed medicines training, their competency had still not been assessed.”
critical“safer recruitment procedures were still not being followed to ensure staff were suitable to work with people who used the service.”
governance
2 findings
critical“A range of internal audits had not been carried out...The date for this to be actioned was 30 November 2022, but this had not been done.”
critical“The provider failed to have effective quality auditing systems and processes to assess, monitor and improve the quality and safety of the service.”
record keeping
2 findings
moderate“there were examples where times for care visits had not been recorded and tasks were being completed that were not part of the agreed care.”
critical“Interview assessment records were still not being completed and any gaps in employment histories were not recorded. References for all four staff files had not been verified”
leadership
2 findings
critical“At the time of our inspection there was not a registered manager in post. The previous registered manager deregistered on 15 June 2022.”
critical“the CQC assessed them as being unable to demonstrate the full understanding of the registered manager role and was unclear on aspects of the management of the service.”
care planning
1 finding
critical“The care records and risk assessments we reviewed continued to lack any specific detail or guidelines for staff to follow to mitigate any possible risks.”
consent capacity
1 finding
critical“The provider was still not working within the principles of the MCA. Mental capacity assessments were not carried out or recorded at the initial assessment.”
supervision appraisal
1 finding
moderate“there continued to be no formal records of shadowing or supervision. The nominated individual acknowledged this”
infection control
1 finding
moderate“the provider did not have systems in place to ensure staff were following the current government guidance for COVID-19 testing requirements.”
person centred care
1 finding
moderate“information in some people's care plans continued to be basic and lacked detail about how people liked their care to be provided.”