critical“One staff member who was administering medicines had not had their competency checked within the previous 12 months.”
critical“Medicines records did not accurately record when medicines were administered and how many were left in the home.”
moderate“Protocols were not always in place to ensure staff had the guidance needed to offer these medicines to people consistently when they needed them.”
critical“Medicines were not always accurately recorded or regularly checked, to show people received their medicines when they should. Mistakes in the recording of medicines had not been identified or investigated.”
governance
2 findings
critical
“Audits to identify issues with medicines were not effective for the last three inspections. This was a breach of regulation 17(1).”
moderate“some audits did fall short in identifying some of the concerns we found. This was because they had not included all areas of best practice within each audit.”
incident learning
2 findings
moderate“There was no ongoing analysis to identify if there were any trends in the incidents. This meant opportunities to improve care could be missed.”
minor“analysis of incidents over time was missing and so the registered manager may miss opportunities to improve the care provided.”
record keeping
2 findings
moderate“Fluid intake was not well recorded meaning we could not be sure people were being offered enough to drink.”
moderate“one person's medicine records showed that they had one more of dose a controlled medicine in stock than was in the cupboard due to an error being made when transferring figures to a new page.”
infection control
1 finding
critical“Some areas of the home were not clean... some beds which had been made, had dirty bedsheets. High level cleaning was inconsistent and there were cobwebs in places. Toilet brushes were not clean”
care planning
1 finding
moderate“the care plans for people who received care in their own home lacked personalised information on risks to keep them safe.”
staff training
1 finding
moderate“Moving and handling training had not been completed and staff's abilities to move people safely had not been assessed.”