critical“We found multiple gaps in recording on people's medicines administration records (MAR). The registered manager had not investigated these gaps so was not able to assure themselves people had been given their medicines as prescribed.”
critical“1 person was administered their medicine every other day but their MAR instruction said it was to be given daily. The registered manager was not sure what the prescribing instruction should be.”
care planning
2 findings
moderate“Records were conflicting as they recorded the person's skin was intact but also the person's skin had a pressure ulcer. Guidance was for staff to re-position them regularly. It was not clear what regularly meant.”
critical“For a person who was at risk of falls we found they did not have a risk management plan. This meant staff had no guidance on what to do to reduce the risk of the person falling.”
governance
2 findings
critical“Governance systems were not effective in identifying improvement needed. For example, the provider had carried out audits of medicines, but not recorded checks on people's medicines records.”
moderate“The provider's policies and procedures had not been updated to reflect the electronic recording systems. This meant procedures for staff to follow were out of date and not relevant to the systems in use.”
staff training
1 finding
critical“Some staff had not received practical moving and handling training. Whilst they had been provided with e-learning training they had not been shown how to move people safely. They had also not been assessed as competent.”
staff competency
1 finding
moderate“We found 2 members of staff were working with 1 person who needed re-positioning regularly. The registered manager and provider told us these staff had been shown techniques and would have the training needed following our inspection.”
record keeping
1 finding
moderate“Care plan audits were carried out but did not identify which care plans had been checked. This meant actions identified were not specific to which care plan was needing the improvement.”
complaints handling
1 finding
minor“The complaints policy directed people to share their complaint with CQC. This was misleading for people as CQC do not investigate individual complaints. The details for the Local Government Ombudsman were not on the policy.”