moderate“risk assessments had been undertaken in 2012 and they had not been reviewed.”
moderate“Care plan reviews were not always recorded, and people's risk assessments were not always updated when people's needs had changed.”
minor“Care plans were reviewed. However, records of actions carried out were not always recorded.”
minor“Care plan records did not contain the dates of previous health checks because the information had been archived.”
staff training
2 findings
moderate“not all staff had received a yearly update in administering suppositories...Training for staff in this area had expired two months ago.”
moderate“insufficient systems in place to ensure that this training was completed promptly, or that staff had understood the training they were required to complete.”
governance
2 findings
moderate“audits had not picked up on what we found during our visit...some audits had stopped occurring six months ago.”
critical“registered manager had failed to submit appropriate safeguarding notifications to the CQC. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”
consent capacity
1 finding
critical“two people who used the service may have lacked the capacity to make some decisions. However, we could not see that mental capacity assessments or best interest decisions had been carried out.”
staff competency
1 finding
minor“medicine competency checks...some of these checks had occurred in the last year whilst others were over three years ago.”
safeguarding
1 finding
critical“safeguarding concerns were not investigated promptly and the registered manager had failed to take prompt action to identify if any improvements or changes to people's care were needed.”
incident learning
1 finding
moderate“accidents and incidents were not analysed in any depth to identify trends or areas where the service could improve. Each incident was reviewed in isolation.”
care planning
1 finding
moderate“a wide selection of people's care plans were not reviewed on a regular basis to ensure they were accurate and up to date.”
medication management
1 finding
minor“Weekly checks were regularly carried out by support workers. However, monthly support officer audits were not carried out consistently.”
other
1 finding
minor“A community learning disability nurse told us that the service needs to, 'get better at problem solving for themselves as they can be over reliant on professionals'.”