minor“Where 1 persons MAR had not been signed as administered, the daily records confirmed it had been given. The registered manager confirmed they would take action to ensure all staff understood the process.”
critical“Accident records had no details of the action taken and did not confirm management had reviewed them.”
care planning
2 findings
minor“One person's risk assessment was brief, the director confirmed they had taken action to ensure this record had been reviewed and was more detailed.”
moderate“Care records for one person did not contain detailed information about the management of a medical condition.”
governance
2 findings
moderate“At our last inspection the provider had failed to ensure systems were robust enough or developed to demonstrate good governance. This was a breach of Regulation 17.”
critical“Audits book was being completed. However, this had not been done since January 2022 and had no evidence of any audits, the findings or the actions taken.”
consent capacity
1 finding
minor“Some staff required further guidance to ensure they understood how to protect people. The registered manager and director said they would take action to ensure all staff fully understood MCA requirements.”
medication management
1 finding
moderate“There was no record of completed competency checks for medicines administration.”
incident learning
1 finding
critical“We saw an incident that required a statutory notification to be submitted. However, this had not been submitted to the Care Quality Commission when required.”
supervision appraisal
1 finding
moderate“More spot checks on care delivery and supervisions were required. This would demonstrate staff had the skills to deliver care to people.”
staff competency
1 finding
minor“New staff told us they completed a detailed induction. However, records to confirm what had been covered had not been done.”