critical“We could not be assured that staff had the required understanding of safe medicine administration. Not all pre-completed medicines administration record (MAR) were available”
care planning
1 finding
critical“Care plans did not always identify risks to people, or record risks in sufficient detail to show how they were managed and mitigated. This included risks from choking and behaviours”
governance
1 finding
critical“Governance processes and systems to monitor the safety and quality of the service were either not in place or effective enough to ensure reliable oversight of the service.”
incident learning
1 finding
moderate“there was no recorded oversight for identifying any trends and help prevent any future risk and reoccurrence. This meant we could not be assured that lessons were learnt”
staff training
1 finding
moderate“Recruitment processes were not consistently applied... We found some pre-employment checks, and employment histories were not always recorded prior to staff being employed”
safeguarding
1 finding
moderate“the safeguarding policy did not list all forms of potential abuse and did not reflect current guidance. The registered manager provided us with a revised policy after our inspection, but this referred to outdated government policies.”
complaints handling
1 finding
moderate“We could not be assured complaints were managed consistently as complaints and any responses, were not recorded. It was not clear how complaints were investigated”
person centred care
1 finding
moderate“Insufficient consideration had been given to the recording of person-centred information such as people's preferences, likes and dislikes and interests in their care plans.”
end of life care
1 finding
moderate“We could not be assured that people's end of life care needs and decisions around their end of life care would be met... care records did not contain details about people's decisions and wishes”
record keeping
1 finding
moderate“Care records were basic, incomplete and did not always adequately document people's care and support needs, which meant people were at risk of not receiving appropriate care”
leadership
1 finding
moderate“The registered manager needed to improve their understanding of quality performance, risk and regulatory requirements. Systems and processes did not always operate effectively”