critical“PRN protocols could not be located...MAR record had been crossed through without signatures to confirm administration...medicines stored in three locations not subject to regular temperature monitoring.”
safeguarding
1 finding
critical“One person's relative told us they had raised concerns in June 2022 regarding alleged unexplained injuries...no safeguarding referral had been made to the local authority. We raised a safeguarding alert.”
care planning
1 finding
critical“One person's risk assessment in relation to their mobility included non-specific guidance...no specific care plan or risk assessment in place in relation to the person's PEG care.”
governance
1 finding
critical“Audits had been inconsistently completed and did not effectively drive improvements...Most progress comments were added on 31 January 2023 after the commencement of our inspection.”
record keeping
1 finding
critical“Care records were incomplete, not always up-to-date and did not consistently represent people's individual needs...confidential records stored in the dining area at one setting.”
consent capacity
1 finding
critical“Mental capacity assessments were not consistently completed in line with the Mental Capacity Act 2005...some best interests checklists had been completed after the assessor documented that the person had mental capacity.”
infection control
1 finding
critical“Cleaning schedules were in place for toilets and bathrooms, however despite these being fully completed these areas were not cleaned to a satisfactory standard.”
staffing levels
1 finding
moderate“Sometimes always short staffed, don't think we have enough staff on every shift…makes work more strenuous…for service users, think affects them too.”
staff competency
1 finding
critical“Medicines competency records were not available for all staff...no evidence was available that staff were trained and competency assessed to assist with the nebuliser.”
incident learning
1 finding
critical“The service had failed to submit notifications to CQC in line with requirements, including the failure to notify CQC of some instances of alleged abuse.”
supervision appraisal
1 finding
moderate“Supervisions had not been conducted at frequencies in line with the provider's policy. Most supervision records reviewed contained minimal detail.”
leadership
1 finding
moderate“One registered manager demonstrated a lack of awareness about the frequency of incidents such as a person's seizures and struggled to locate routine paperwork during our visit.”
person centred care
1 finding
moderate“My son doesn't get any exercise...She is not really encouraged to try new things…as far as I can gather she has only been out with staff once in the last year.”
communication with families
1 finding
moderate“Some relatives told us they had not received sufficient feedback when people had sustained injuries to help them understand how these injuries may have occurred.”
other
1 finding
critical“Staff recruitment practices were not always fully followed...CVs were routinely accepted...gaps in employment history were not consistently identified and explored.”