critical“staff did not update a person's MAR when their doses of a blood thinning medicine Warfarin had changed, meaning the person could have been given the wrong dose”
moderate“Some of these MARs were not signed by staff or an appropriate code used when medicines were not given.”
staffing levels
1 finding
critical“in the week of 1 November to 7 November 2021, staff were not always available on duty to meet people's assessed needs. The rota showed for 34 ½ hours where staff were working alone.”
person centred care
1 finding
critical
“guidance provided for staff in people's records was inaccurate, which may have put people at risk of receiving inappropriate care.”
consent capacity
1 finding
critical“Records showed a person was restricted from leaving the service on their own. The person's care records had no mental capacity assessments and Best Interests meetings outcome documents.”
care planning
1 finding
moderate“we found people's records were not always updated on the new computerised system and people's care files contained the previous provider's care documents.”
record keeping
1 finding
moderate“the medicines administration records were of a poor quality and not completed accurately.”
governance
1 finding
critical“The provider undertook some audits; however, these did not find the concerns we found with poor medicines management, people's social needs not always being fully met, inconsistent staffing levels”
leadership
1 finding
moderate“The registered manager had a lack of oversight of the service including the ineffective monitoring of the service.”
communication with families
1 finding
moderate“records we viewed did not show any consistent involvement of people or their relatives in their care plan reviews.”
incident learning
1 finding
critical“We were made aware of two incidents in September 2021 where the police were involved. However, CQC were not informed of this”
staff training
1 finding
moderate“A staff member said they had completed a one-day training in Makaton... During our visit we did not see staff use this form of communicating with anyone who had these specific communication needs.”
cultural competency
1 finding
minor“We found care records did not routinely include people's protected characteristics and how they impacted people's life, health and well-being.”