critical“room and fridge temperatures where medicines were being stored, were not always recorded daily. In September 2023 temperatures were only checked on 8 days.”
moderate“Not all medicines prescribed to be administered as and when required (PRN), had guidance in place to inform staff when they would be appropriate to be given.”
care planning
1 finding
critical“people were not always protected from the risk of unsafe care as their care needs and associated risks had not been routinely assessed, updated and monitored.”
safeguarding
1 finding
critical
“Following the inspection we made 4 safeguarding referrals to the local authority about people's care and support.”
governance
1 finding
critical“Quality assurance and governance systems...had failed to identify when people had lost weight, had not received sufficient to drink or were not having their diabetes monitored effectively.”
consent capacity
1 finding
critical“mental capacity assessments and best interests decisions had not always taken place. This meant that restrictions may be placed upon people that may not be appropriate.”
incident learning
1 finding
moderate“there was no process in place to analyse accidents and incidents on a wider scale therefore identifying potential accident/incident areas within the service.”
staff training
1 finding
moderate“there were gaps in the staffs' training. The finance manager told us they had identified that there were gaps in staff training and had produced a training plan.”
supervision appraisal
1 finding
moderate“The management team told us they had identified that the frequency of formal staff supervision and appraisal needed improvement.”
record keeping
1 finding
moderate“audits were not in place to review people's care plans and some records had not been reviewed for a number of months.”