critical“No risk assessments or care plans had been completed for people with specific healthcare needs, including epilepsy, diabetes and catheter care.”
medication management
1 finding
critical“Training records showed only 1 of the 7 staff members had completed medicine management training. The registered manager told us, no staff competencies to administer medicines, had been completed.”
staff training
1 finding
critical“Staff training records showed staff had not completed all the providers mandatory training in topics such as medicine management, mental capacity and DoLs, first aid, and children's safeguarding.”
governance
1 finding
critical“There was no auditing system in place. This meant the service had not been operating effectively and had failed to identify the concerns we found during the inspection.”
staffing levels
1 finding
critical“The provider had not adhered to safe recruitment practices. Of the 6 staff files looked at, full employment histories had not been provided on 5.”
incident learning
1 finding
critical“There were no records of any accidents or incidents, therefore we were not able to check records to see what action had been taken in response.”
safeguarding
1 finding
critical“The provider told us about an incident that had taken place, but this had not been recorded, the provider told us it was passed on verbally from a staff member.”
consent capacity
1 finding
moderate“No staff had completed training in people's rights under the MCA and when to act in their best interests to ensure people's safety and welfare was maintained.”
person centred care
1 finding
moderate“People's care plans were not personalised and did not reflect people's wishes and choices. Although relatives told us their family members care had been discussed with them, this was not reflected in people's care records.”
record keeping
1 finding
moderate“The provider had failed to identify that accurate records relating to people's care were not being maintained, to ensure staff had access to consistent and accurate information.”
supervision appraisal
1 finding
moderate“The provider had failed to assess the effectiveness of the training given to staff. For example, spot checks and competency assessments were not completed.”
staff competency
1 finding
moderate“Induction training was completed in one day and involved looking at policies and procedures. There was no system for new staff shadowing staff or having their competencies assessed prior to carrying out their role.”