critical“there were no "as required" protocol's in place or the details of prescribed medicine was no longer current”
critical“Medicine Administration Records (MARs) did not always evidence medicines were offered or the outcomes of administration recorded accurately”
care planning
1 finding
critical“people requiring continence care did not have specific risk assessments in place for staff to follow or to monitor people's skin integrity due to these needs”
staffing levels
1 finding
moderate“We found there was not always sufficient numbers of care staff in place to ensure care visits were completed as required”
missed or late visits
1 finding
moderate“One person told us their night time care calls were cancelled at short notice. The registered manager confirmed this was due to shortness in staff”
staff training
1 finding
moderate“where staff had received specialised training for people's needs, for example catheter care or swallowing difficulties; they felt the availability and quality of training could be improved upon”
staff competency
1 finding
moderate“there were clear differences in the level of knowledge and confidence of staff when carrying out this care”
governance
1 finding
critical“Auditing of care documentation did not always identify issues relating to recording of risk assessments and medicine administration”
record keeping
1 finding
moderate“The service did not record service schedule dates for equipment used to support people's mobility; and therefore, could not be assured the equipment was safe to use”
leadership
1 finding
moderate“The provider did not always have effective strategies in place to manage shortfalls in staff numbers”
safeguarding
1 finding
minor“one member of staff did not have a new DBS check completed within a reasonable time period”