minor“After a number of documentation errors had been identified during monthly audits, a robust action plan had been implemented to address these errors.”
critical“We looked at peoples medication administration records (MAR) and found three had multiple gaps...the gaps in the MAR meant they may not have received their medicines correctly”
moderate“care staff were placing medication for one person into a pill pot so they could take them whilst they were at a day centre. The providers policy stated, 'care staff must not put out individual doses'”
care planning
3 findings
moderate“The provider had not routinely completed capacity assessments; however care and support was being provided to people who were living with dementia type illness.”
moderate
“Care plans focused on the specific tasks care staff were required to undertake...had limited reference to a person centred care approach.”
moderate“one person's risk assessment identified that they were living with diabetes however there was no reference to this within their care plan.”
governance
2 findings
critical“The issues identified with governance are a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
moderate“There was no system in place to record or collate late or missed care calls...no system for trends to be identified or to evidence staff learning from these.”
consent capacity
1 finding
moderate“The provider did not have a consistent approach to assessing people's the mental capacity. Care documentation did not consistently identify how best interest decisions had been reached and who had been involved.”
record keeping
1 finding
moderate“people's most recent MAR documents to return to the office were dated July 2015, this delay meant any meaningful audit process to highlight concerns in a timely manner would be missed.”
staff training
1 finding
moderate“two new starters induction paperwork was not complete and neither the provider nor personnel manager could confirm what aspects of their induction they had completed.”
safeguarding
1 finding
moderate“one staff member was unsure of who to report suspected abuse to other than 'the manager'...another...had not had their safeguarding training refreshed yet had been back for five months.”
incident learning
1 finding
critical“We identified a recent safeguarding incident which had not been notified to us; however the service had notified the Local Authority.”
leadership
1 finding
moderate“The provider had failed to keep their registration updated correctly...registered to provide two regulated activities however they were only providing one of these.”