minor“We found one person's medicine record had not been completed accurately or checked.”
moderate“The tools in place were not robust enough to give assurance of clear oversight of processes. This increased the risk of medicine error not being identified promptly.”
governance
2 findings
moderate“The quality monitoring processes were not always robust...oversight of quality audits in areas such as medicines and care plans being intermittent.”
moderate“their disciplinary policy did not give managers clear guidance on how to proceed with disciplinary processes if a member of staff left the service before they had completed their investigations.”
consent capacity
1 finding
moderate“staff did not always demonstrate best practice around documentation of assessment of mental capacity to show the least restrictive options had been undertaken”
record keeping
1 finding
moderate“we saw care plans for people being supported in one location had contradictory information and had not been reviewed on a regular basis”
care planning
1 finding
moderate“The information in people's care plans varied at different locations. Some information was contradictory and had not been reviewed to ensure it was still relevant to people's needs.”
supervision appraisal
1 finding
minor“there were some staff in some areas of the service who had not had regular supervision recently.”
staffing levels
1 finding
moderate“The service did not always have enough appropriately skilled staff to meet people's needs.”
communication with families
1 finding
minor“one relative said, 'Lately I feel uncomfortable, more communication would be nice...managers don't. No one answers the phone.'”
staff training
1 finding
minor“The training matrix showed some staff training was not up to date, the provider had a plan in place to address this.”
safeguarding
1 finding
critical“The inspection was prompted in part due to Safeguarding concerns and staff culture.”