minor“we found one person's behaviour guidelines could have been more detailed to include, tips for staff on how to defuse situations before their behaviours escalated.”
moderate“The risk assessments we saw were not always amended or reviewed in order to provide staff with the necessary guidance and instructions to reflect these changes.”
staff competency
1 finding
minor“the director told us, they did not follow all the principles of the certificate such as competency checks for each element of the training staff had completed.”
person centred care
1 finding
minor
“we identified a situation, where professional boundaries may not have always been upheld. We discussed this with the registered manager who was not fully aware of the situation.”
staffing levels
1 finding
critical“The registered provider's recruitment procedures were not suitably effective to protect people from unsuitable staff gaining employment.”
record keeping
1 finding
moderate“Records were not always completed by staff to demonstrate they had administered people's medicines as prescribed by a health care professional.”
governance
1 finding
moderate“The systems in place by the provider to monitor, check and review the quality of the service were not effective means in identifying any concerns or shortfalls in people's care.”
supervision appraisal
1 finding
minor“Some staff believed they received support and guidance however, others did not feel so supported and rather on their own.”
medication management
1 finding
moderate“The medicine records we saw contained gaps and lines across areas where staff should have signed for items as administered.”