minor“Staff did not fully understand the legal requirements for the management of controlled drugs.”
critical“we found gaps on people's Medicines Administration Record (MAR) sheets”
critical“We saw medicines were being stored in unlocked cupboards... When we returned for the second day, they remained unlocked.”
safeguarding
2 findings
critical“The provider did not have adequate systems to protect people from the risk of financial abuse. Money belonging to people was paid directly into the provider's business account.”
critical
“People were not safeguarded from the risk of abuse. The provider had not ensured staff had been trained in safeguarding or how to identify abuse.”
care planning
2 findings
critical“There were no care plans in place around people's needs related to equality and diversity needs. There were no care plans in place around end of life care for people.”
critical“Risks to people were not always recorded nor was information on how to mitigate those risks.”
governance
2 findings
critical“Quality assurance and monitoring systems were in place, but these were not always effective... had failed to identify that risk assessments did not cover all significant risks.”
critical“There were numerous shortfalls in the governance of this service... Governance at the service was lacking. The service did not have adequate quality assurance in place.”
record keeping
2 findings
critical“The provider had failed to implement robust systems to protect people from the risk of financial abuse... no auditing or recording of how much money was spent on behalf of people.”
critical“the provider had failed to maintain accurate records in relation to the management of regulated activity”
supervision appraisal
2 findings
moderate“A director told us they had regular one to one supervision with staff but that this was not always recorded, saying, 'These were not written down, they were oral.'”
moderate“The registered manager told us they had not provided supervision to staff. The provider told us they had given supervision but had not recorded it.”
person centred care
1 finding
moderate“People did not have Personal Emergency Evacuation Plans (PEEPs) in place... The nominated individual told us they did not know this was required.”
staff training
1 finding
critical“We found no evidence staff had been trained to administer medicines or had been competency assessed to do so.”
staff competency
1 finding
critical“Staff recruitment measures were not robust... Two of the three staff had their DBS checks completed following the inspection”
incident learning
1 finding
moderate“Lessons were not always learned when things went wrong. Incidents and accidents were not always recorded as such.”
leadership
1 finding
critical“The management of this care home was inadequate... they exhibited a lack of understanding of what was required to manage a care home.”
communication with families
1 finding
minor“The provider told us they held meetings with staff and people but told us none of these were recorded”