critical“The medicines fridge, which contained insulin was unlocked on both days of the inspection with the key in the door.”
critical“Medicine records were not always accurate. One person's medicine, signed as administered, was still in the person's bedroom not taken.”
critical“Records to show topical preparations such as creams were being applied were not always completed; therefore, we were not assured people were receiving these medicines as prescribed.”
care planning
2 findings
critical“One person's risk assessment and care plan said they were at risk of choking, needed their food cutting up...We saw this person's food was not fully cut up and they ate alone.”
critical
“Care plans were not always consistently reviewed and updated as people's needs changed...we were not assured care plans and risk assessments were always person centred.”
safeguarding
2 findings
critical“One person had raised an issue of possible financial abuse. This had been referred to safeguarding but the person was still experiencing the same issue.”
critical“The referral form said anybody around the person were at risk of violence and aggression...We did not see evidence of any safeguarding referrals having been made.”
staffing levels
2 findings
critical“Two people told us there were not enough staff to respond to their call bells in a timely way. Both said they had been incontinent because of the wait.”
moderate“People and their relatives told us there were a number of occasions when there were insufficient care staff. One person told us staff shortages meant call bells were not being answered quickly.”
infection control
2 findings
critical“A catheter bag containing urine had been left in one person's bedroom and the bed rails in this room were heavily soiled.”
moderate“We noted dirty bedding and furniture in some people's bedrooms. Bumpers covering bed safety rails in some rooms were torn. This made effective cleaning difficult.”
consent capacity
2 findings
critical“There was conflicting information in people's care files relating to capacity...a mental capacity assessment said the person lacked capacity...another form said the person had capacity, but was signed by a relative.”
critical“One person's care records included a DoLS application dated August 2021. There was no evidence of the application having been followed up.”
governance
2 findings
critical“Effective systems were not in place to monitor the quality and safety of the service. Learning had not always been taken from the results of audit.”
critical“Governance systems where not always effective in ensuring oversight of the safety of the service...breach of regulation 17 (Good governance).”
person centred care
2 findings
moderate“Activity records for another person with a learning disability showed the only activity they had engaged in for a period of 18 days was watching television.”
moderate“One person told us they had been forced to be incontinent as staff did not come quickly enough to support them to the toilet. The person was very distressed by this.”
record keeping
2 findings
moderate“There was no recording of the application site for over 6 weeks. Record of application site is needed to prevent skin irritation.”
moderate“Fluid charts for a person with a medical condition said they needed 1500 and 2000mls of fluid per day. Fluid charts for four consecutive days showed an intake of between 700 and 750mls.”
incident learning
2 findings
moderate“The manager was working with the local authority to develop their skills in analysing accidents and incidents looking for patterns and trends.”
minor“We saw at a handover meeting that some staff were not clear about how to report and record incidents.”
end of life care
2 findings
moderate“One person's documentation said, 'I don't not have a DNCPR'...Information in relation to 'Do not attempt resuscitation' orders was also not always made clear on people's hospital passports.”
minor“The care records we reviewed did not have care plans in place to consider people's individual wishes, values and beliefs at the end of their lives.”
leadership
1 finding
moderate“The manager said they did not complete a daily walkaround to make sure the service was clean and safe...The manager had not undertaken any training in relation to managing a service.”
staff training
1 finding
minor“One staff member said they didn't know who to go to if they hadn't understood something and would prefer face to face training so they could ask questions.”
communication with families
1 finding
minor“The manager had not provided the nominated individual with a clear overview of the feedback we provided to them on the first day of our inspection.”
supervision appraisal
1 finding
moderate“Some staff told us that this was approximately only once over the last year. This meant staff and their supervisors had limited opportunity to discuss their work.”
staff competency
1 finding
moderate“Care staff competency assessments to administer medication had not been completed in line with the provider's own policy.”