minor“medication audits had not identified that codes were not always being recorded by staff”
critical“We found several gaps in medication administration records (MARS); these had not previously been identified by the provider. We could not be sure if these were recording issues or if people's medication had been missed.”
governance
2 findings
minor“we also found examples when these had not been fully effective in identifying areas for improvement”
critical“The provider had failed to ensure the quality assurance processes in place were effective. Audits had either not been completed or those completed had not identified issues found at this inspection.”
safeguarding
1 finding
critical“There had been occasions when safeguarding concerns had not been appropriately reported by the provider. This was a breach of regulation 13.”
consent capacity
1 finding
critical“We found some people who lacked capacity in relation to their care, had their liberty restricted as part of their care arrangements. This had not been previously identified by the provider.”
care planning
1 finding
moderate“People's care plans lacked detail in relation to important areas of their care, their preferences and how staff should support them.”
record keeping
1 finding
moderate“Records were not always accurate, complete or contemporaneous. We found several concerns around the quality and accuracy of the records.”
supervision appraisal
1 finding
moderate“Supervisions were not always happening in line with the provider's policy or being documented.”
staff competency
1 finding
moderate“The system in place to check competency of staff in this area was not robust. Medication audits were not being completed by the provider.”
leadership
1 finding
critical“The provider's knowledge and understanding of regulations, best practice guidance or its own policies and procedures was limited.”
person centred care
1 finding
minor“People's protected characteristics under the Equality Act (2010), such as religion and disability were not documented as part of the assessment process.”