critical“Medicine records did not contain the required information to ensure people received their prescribed medicines safely... no instructions in place relating to medicines which were required 'as needed'.”
care planning
1 finding
critical“Records contained inaccurate information and were not updated when people's needs changed... care plans did not demonstrate whether this was safe.”
consent capacity
1 finding
critical“People's human rights were not always respected with appropriate mental capacity assessments and best interest decision making documented.”
governance
1 finding
critical“The provider failed to have oversight of the service, to ensure care was high quality and improvements were made. This was a breach of regulation 17.”
record keeping
1 finding
moderate“Records we reviewed were not well personalised and did not always reflect the care that people were receiving.”
supervision appraisal
1 finding
moderate“Staff Supervisions were infrequent... the deputy manager had not had any formal supervisions since starting in post in April 2022.”
incident learning
1 finding
moderate“Documentation of actions and outcomes following incidents had only been recently implemented. Incident analysis needed further embedding to ensure lessons were learnt in a timely manner.”
end of life care
1 finding
moderate“The service did support people with life limiting conditions and there were no end of life care plans in place for those people.”
staff training
1 finding
moderate“Not all staff had completed an interview or had two employment references completed.”
person centred care
1 finding
minor“Care plans did not always accurately describe people's history, their background, goals, likes and dislikes.”
communication with families
1 finding
minor“Communication needs had not always been fully assessed. A communication care plan we reviewed was generic and did not adequately direct staff.”