critical“Not all medicines being administered by staff were recorded on the MAR. For example, 1 person had recorded in their notes they were being given paracetamol and eye drops by staff. Staff had not recorded the dose given.”
care planning
1 finding
critical“Risks to people's safety had not always been identified so management plans could be put in place. Where risks had been identified, management plans were not robust and did not provide clear guidance for staff.”
staffing levels
1 finding
critical“The provider had failed to obtain full employment histories for all staff. The provider had failed to assess risks of starting staff working without a full Disclosure and Barring Service (DBS) check.”
governance
1 finding
critical“Governance systems in place were not effective. Shortfalls found in this inspection had not been identified by the provider. Audits being completed were ineffective and not identifying areas for improvement.”
record keeping
1 finding
moderate“Audits had not been carried out on daily records. This meant the provider had not identified staff were administering medicines which were not recorded on MAR. Some daily notes were not accurate.”
safeguarding
1 finding
critical“The provider had failed to notify us of all safeguarding concerns. We found 1 incident which had been reported to the local authority, but not notified to CQC as required by law.”
staff training
1 finding
moderate“There was no training provided for how to support people with Autism or a learning disability. Staff had also not been provided with practical moving and handling training.”
staff competency
1 finding
minor“Staff had been provided with training on medicines and had their competence checked. However, there were no dates recorded on the competence checks to demonstrate when staff had been assessed.”
incident learning
1 finding
minor“The registered manager had reviewed this incident and taken action to prevent recurrence, however, this had not been recorded in full.”