moderate“the dose to be given a person as guidance for staff, had not been recorded on the MAR.”
moderate“no guidance was in place for staff to follow regarding these triggers, the maximum dose they could administer in 24hour period”
moderate“Some medicines recorded within peoples care plans were spelt incorrectly. The same medicine was spelt differently several times within one person's care plan.”
incident learning
3 findings
moderate“Concerns raised by an external care professional regarding staff practice had not been thoroughly investigated.”
moderate
“staff did not receive this training until two months later.”
critical“we found two issues that had not been appropriately reported to the safeguarding team. We raised these as safeguarding issues with the local authority.”
governance
3 findings
moderate“these were not sufficiently robust and had not identified the shortfalls we found during this inspection in relation to medicine records and investigations.”
moderate“the registered manager had not sent us all the required notifications...information about important events that the provider or registered manager is required by law to notify us about.”
moderate“no additional quality audits in relation to areas such as care plans and risk assessments had been completed”
record keeping
3 findings
moderate“staff sometimes helped them with to take their medicines from the container. This was not reflected in their care plan and put the person at risk of receiving the wrong medicine.”
minor“although risk assessments had been completed there was not always formally recorded information for staff as guidance on what they should do in the event of the risk occurring”
moderate“Where people's needs changed staff were able to tell us about the changes. However the changes had not been updated and recorded in the care plan”
care planning
1 finding
critical“staff were providing food and medicines via special methods through the stomach, and this was not recorded as part of the care plan”
safeguarding
1 finding
critical“People were controlled and restrained without the required authorisation under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards”
consent capacity
1 finding
critical“People's capacity under the Mental Capacity Act 2005 had not been assessed to ensure decisions that were taken were in their best interest”
staff training
1 finding
moderate“Staff were not trained in the principles of the Mental Capacity Act 2005 (MCA) although some could describe how people were supported to make decisions.”