critical“Risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient and accurate detail to help staff understand and respond to risks.”
medication management
1 finding
critical“The MARs viewed did not include all the medicines prescribed to people and that were being administered by staff, including the application of topical creams.”
staff training
1 finding
critical“Training certificates were not available to evidence the specialist training recorded on the matrix had taken place.”
staff competency
1 finding
critical“Staff were signed off to work unsupervised without being assessed as safe and competent in tasks they were involved in, such as medicine administration and moving and handling.”
safeguarding
1 finding
critical“In 7 out of the 12 staff files viewed we found staff had worked without a DBS check in place and there was no risk assessment to indicate this had been identified.”
incident learning
1 finding
moderate“16 alerts of incident that occurred between 5 May 2023 and 14 June 2023 were logged and marked as 'Action needed'. Records had not been updated and closed by a manager.”
governance
1 finding
critical“Audits were not undertaken in line with the provider's policy and no audit schedule was in place. Where audits did take place, these had not been effective in identifying the concerns we found.”
record keeping
1 finding
critical“Records were not suitably maintained, in that information within care plans and risk assessments was not always accurate and up-to-date. Some records contained contradictory information or were undated or incomplete.”
consent capacity
1 finding
critical“The service was not working within the principles of the MCA as MCAs and best interest decisions were not decision specific. Some MCAs were either not in place or were not completed in a timely manner.”
supervision appraisal
1 finding
moderate“Gaps in the spot checks and supervisions for a number of staff and for other staff records were not on file to confirm the spot checks and supervisions recorded on the matrix had taken place.”
end of life care
1 finding
minor“At the time of our inspection the training matrix showed the current staff team had not received end of life care training.”