critical“1 person's medicine records stated they had not been administered, whilst daily notes said staff had been there. This meant systems could not assure that people received their medicine as prescribed.”
critical“One person was at risk of choking or aspiration because they had been administered tablets whilst on a specialist soft diet. No instructions were in place.”
moderate“Only two out of four members of staff had received a medicines administration competency assessment within the last 12 months... audits had not been completed for September and October 2021.”
safeguarding
2 findings
critical“1 incident had to be notified to CQC retrospectively because the registered manager had not recognised it as potential abuse.”
moderate
“the details of this incident were not in the service safeguarding file, there were no actions or outcomes recorded. This meant the incident and any actions and outcomes were not effectively monitored”
governance
2 findings
critical“Audits which had been completed identifying actions needed to be taken were incomplete. An audit in May and June 2023 had identified risk assessments had not been completed; by July 2023 this was still the case.”
critical“Not all records were accurate or up to date. We found some shortfalls in recruitment and training documentations. Not all monitoring systems were accurate and up to date”
incident learning
2 findings
critical“We were informed about an incident which was a potential safeguarding...no records were shared with us despite requesting them.”
critical“the accident and incident log showed events which should have been reported to CQC as a Notification. We were not assured that all safeguarding incidences were recorded or referred appropriately.”
record keeping
2 findings
moderate“Information that should have been readily available was not accessible throughout the inspection. On the first day a comprehensive list of people receiving care was requested on 4 occasions.”
critical“Not all accidents and incidents were recorded. One incident was reported in the handover book but had not been added to the log. The audit had not identified this omission.”
consent capacity
2 findings
moderate“People's care plans did not always reflect what we were being told or demonstrate people's capacity had been considered in line with current legislation.”
moderate“The registered manager did not give us assurances they fully understood the MCA, different legal representations or Deprivation of Liberty Safeguards procedures in the community.”
staffing levels
1 finding
critical“One staff member was found to be lone working without an up-to-date British criminal record check in place. No risk assessment was in place to support this potential risk.”
staff competency
1 finding
critical“Staff employment history had not been checked in line with current legislation or their own policy. Gaps in employment had not always been recognised and checked.”
care planning
1 finding
critical“Risks to people lacked guidance in place to mitigate the risks. People's care plans contained little to no risk assessments in line with best practice, statutory guidance and legislation.”
leadership
1 finding
critical“Systems were not in place to ensure safeguarding and duty of candour had been followed fully. No suitable level of training had been completed by senior staff.”
staff training
1 finding
critical“Only one member of staff was up to date with the provider's required training. Some certificates in personnel records had incorrect dates on them.”
supervision appraisal
1 finding
moderate“Staff had received induction, supervision and service spot checks but these were not efficiently recorded. Two staff members induction competency checks were not dated.”
other
1 finding
critical“Only one member of staff had all the required recruitment checks in place to ensure safety. For example, appropriate work or character references and complete application forms”