critical“Some medicines administration record (MAR) charts were missing information, some were not dated correctly and some were illegible in parts.”
critical“One person had duplicated MAR charts, which made it unclear how much medicine they had been given.”
staff training
2 findings
critical“Staff medicines training was not up to date. This meant staff lacked current knowledge about how to manage medicines safely.”
moderate“Not all staff had received training that could help them support people with specific needs, for example, dementia care.”
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.”
critical“The provider had not informed the local authority of a potential medicines error resulting from a person having duplicate MAR charts for March 2022.”
care planning
2 findings
critical“People's risk assessments and care plans did not always contain detailed and specific information for staff to manage risks safely.”
moderate“The provider had not reviewed some people's risk assessments for one year and had not reviewed one person's risk assessment when their needs had changed.”
infection control
2 findings
critical“The provider did not have a COVID-19 testing policy in place for staff. COVID-19 testing for staff was not carried out in line with Government guidance”
moderate“The provider had not carried out individual COVID-19 risk assessments for staff.”
governance
2 findings
critical“The provider had not established sufficient systems and processes to effectively monitor and improve the quality and safety of the services provided”
critical“The provider had not carried out regular audits and the audits carried out had not identified the issues we found during the inspection.”
staff competency
1 finding
moderate“Staff did not always have their competency to administer medicines appropriately checked in accordance with guidance.”
incident learning
1 finding
critical“The provider had not carried out accident and incident audits. Therefore, the provider did not have a system in place to learn why things had gone wrong”
complaints handling
1 finding
critical“The provider did not have an effective system in place to record, investigate and respond to complaints.”
missed or late visits
1 finding
moderate“One person had complained about care workers' timekeeping on three separate occasions during a period of seven months”
person centred care
1 finding
moderate“Some people's risk assessments and care plans did not contain detailed personalised information for staff to support them as an individual, in line with their preferences.”
communication with families
1 finding
moderate“if you needed to contact them out of hours or at the weekend, the number given did not work, I found this worrying”
leadership
1 finding
moderate“[registered manger's name] has too many tasks on to fully concentrate on putting the processes in place.”