critical“one member of staff was administering medication prior to completion of adequate medication training and competency check.”
minor“Not all staff had received MCA training”
staff competency
1 finding
critical“One member of staff had started working unsupervised prior to receipt of a disclosure and barring service (DBS) check.”
medication management
1 finding
moderate“The person's care plan included medication that was to be administered at a time they did not have a visit. There was also a discrepancy between the visit instructions section of the care plan and the medication assessment.”
safeguarding
1 finding
moderate“There was a safeguarding policy, but it did not state the correct Adult Safeguarding Team for referrals to be made to.”
care planning
1 finding
moderate“The care plan we reviewed had not been updated in full following the annual review. This meant there was a risk that staff did not have the most up to date information about the person's needs.”
record keeping
1 finding
moderate“We saw gaps in staff recruitment files, such as not having a full employment history or evidencing appropriate references.”
governance
1 finding
moderate“The provider's systems and processes did not identify the shortfalls we found at this inspection.”
communication with families
1 finding
minor“we found that the number provided for the district nurse was not in use.”