critical“Medicines were not managed safely...no clear processes in place for staff to follow when sharing the administration of the person's medicines with another care company.”
critical“Guidelines for 'as required' medicines were not in place for the person, who was unable to make their needs always known, therefore staff had limited direction.”
governance
1 finding
critical“Governance and audit systems were not robust and did not provide effective oversight and monitoring of the service.”
record keeping
1 finding
moderate
“The provider had no system in place for staff to record the times in and out of visits...details of the reviews and the discussions held were not recorded.”
staff training
1 finding
moderate“Staff had received general learning disability training. However...staff had not received in-depth training in relation to their needs.”
consent capacity
1 finding
moderate“Staff did not receive specific training in MCA...The provider assured us they will be facilitating specific MCA training for staff. This was yet to be embedded into practice.”
care planning
1 finding
moderate“Care plans did not contain their life histories, they lacked detail about their preferred routines and care plans did not include detailed information about the person's medical diagnoses.”
end of life care
1 finding
minor“The care plans in place did not consider the person's end of life wishes.”
supervision appraisal
1 finding
minor“Appraisals were not meaningful and consisted of a tick box exercise with limited discussions.”
person centred care
1 finding
minor“In one care plan their continence aid was referred to a 'nappy' and their medication record referred to them as a 'child'.”
staffing levels
1 finding
moderate“Recruitment checks were not always robust...1 staff member did not have a disclosure and barring service (DBS) check facilitated by the provider.”