critical“Medication administration records (MAR's) were not regularly audited. We found a number of gaps on people's MARs.”
moderate“People's MAR's were handwritten, the entries were not signed and countersigned to check their accuracy.”
care planning
2 findings
critical“Care plans did not provide care workers with the necessary information to provide person centred care to people who used the service.”
moderate“One person's care plan states they were living with diabetes with no further detail regarding the support required in relation to this.”
record keeping
1 finding
moderate“There was not a robust system in place to ensure oversight of the quality of people's records to ensure they contained detailed information.”
incident learning
1 finding
critical“The service did not have a system to document and review accidents and incidents. Incidents were reported verbally to the office, however no formal record or review.”
governance
1 finding
critical“Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service. Breach of regulation 17.”
staff training
1 finding
moderate“There were gaps in training for subjects such as dysphagia, oral health, diabetes and catheter care. Some staff also required refresher training.”
staff competency
1 finding
moderate“The provider told us spot checks were completed on staff to check their competencies. However, there were no records demonstrating this.”
person centred care
1 finding
critical“One person's care plan stated they were blind, their care plan did not detail how information should be presented to them. Breach of Regulation 9.”
safeguarding
1 finding
moderate“One recent safeguarding concern had not been reported to the Care Quality Commission (CQC), the provider confirmed they would complete this.”
leadership
1 finding
moderate“At the time of our inspection there was not a registered manager in post. The provider was in the process of applying for the registered manager position.”