critical“People's records did not always provide information as to the medicine people were prescribed, including the name of the medicine, the dosage and times of administration.”
critical“Staff had received training in the safe administration of medicine, however staff were not observed administering medicine to ensure they were competent to do so.”
moderate“Staff who supported some people with their medicines were not always trained to do so.”
governance
3 findings
critical“The provider did not have an effective system in place to assess, monitor and improve the quality and safety of the service. This was a breach of Regulation 17.”
critical
“provider had failed to ensure that the provider's oversight systems and processes were effective. The lack of leadership and management oversight of people's care placed increased the risk of harm.”
critical“The provider's oversight systems and processes remained ineffective. The lack of leadership and management oversight of people's care placed increased the risk of harm.”
leadership
3 findings
moderate“The registered manager had not kept up to date with changes in legislation. The provider was not aware of the Health and Social Care Act 2008 and the Key Lines Of Enquiry (KLOE's).”
moderate“There were limited opportunities for people and staff to give feedback on the service.”
critical“There was a continued lack of effective leadership. The service was managed by the administrative staff member with limited relevant management experience.”
supervision appraisal
2 findings
moderate“The provider did not have an effective system to support staff through supervision. Group supervisions were held by the trainer. However, there was no planned schedule.”
moderate“There was no system to support and supervise staff and to ensure staff were kept up to date about changes to people's needs or practices.”
safeguarding
2 findings
moderate“Staff told us they would report any concerns regarding abuse to the registered manager. However, staff were unclear as to other organisations they could contact.”
moderate“The provider understood their role to act on abuse and report it to relevant external agencies but further action was needed to ensure all staff were trained in this area.”
record keeping
2 findings
moderate“Care plans and risk assessments for medicines did not provide clear information, and sometimes had contradictory information as to the role of staff and family members.”
minor“The registered manager told us some staff practices in the safe moving and handling of people had been assessed by a community nurse, but no record was found to confirm this.”
care planning
2 findings
minor“People's care plans were not consistently clear as to who was responsible for the provision of care...care plans for medication and the provision of meal times, sometimes stated both family members and staff were responsible.”
moderate“care plans were not kept up to date to reflect people's current needs, support required and clear guidance for staff to follow to meet those needs.”
staff training
2 findings
critical“failure to ensure that people who use the service were not at risk of receiving unsafe care and support because staff were not trained, competent and qualified”
critical“Staff had not received induction and essential training in all key areas of care provision to help ensure they had the skills and knowledge to fulfil their roles.”
staff competency
1 finding
critical“one staff member with no experience of working in social care had supported a person for 5 months without completing induction training.”
incident learning
1 finding
moderate“The provider did not have a system to record all incidents and accidents such as falls. Staff were not able to tell us if lessons were learnt as staff meetings were not consistent.”
consent capacity
1 finding
minor“the registered manager was not fully aware of the process for best interest decisions when a person lacked capacity or had fluctuating capacity.”