critical“Medicines which were 'as required' lacked clear guidance to ensure consistent administration. One person...had staff who were not familiar with how to administer their emergency medicine safely.”
care planning
1 finding
critical“Care plans lacked details and guidance for staff in some areas to ensure consistent care...a lack of explicit step by step instructions for how to support people with their health conditions.”
staff competency
1 finding
critical“People with more complex needs did not always have staff who understood their needs or have adequate training.”
staff training
1 finding
moderate“The registered manager and senior staff were assessing competency around medicine administration...They had not completed higher level training to ensure they were following current best practice.”
governance
1 finding
critical“Quality assurance systems were not in place and embedded into practice to ensure people were receiving safe and high-quality care.”
record keeping
1 finding
critical“No start dates could be provided for staff files we checked. Therefore, it could not be determined who had criminal record checks and references prior to starting work.”
safeguarding
1 finding
critical“Recruitment systems were not in line with current legislation or the provider's policy to keep people safe from inappropriate staff working with them.”
consent capacity
1 finding
moderate“Examples were seen when people's health had declined, and no capacity assessments or best interest decisions had been completed for any decisions.”
end of life care
1 finding
moderate“People had not had their end of life plans considered other than legal requirements completed by health professionals.”
incident learning
1 finding
minor“The registered manager showed us the system they were developing to demonstrate they were learning when things went wrong.”