critical“The two records we viewed from two months prior to the inspection did not provide confirmation that people had always received their medicines and creams as prescribed.”
critical“There were some gaps in the recording on the medication records so we could not establish if people had received their prescribed medicine.”
critical“Staff were routinely administering some medication that was only prescribed to be given 'as required' (PRN)...did not have specific protocols available for staff to follow.”
governance
3 findings
moderate“monitoring systems in place they were not robust and in some instances not been undertaken as frequently as planned.”
moderate
“The provider did not have robust systems to audit, monitor and improve the quality of the service within a timely manner.”
moderate“The survey feedback had been not been analysed for any trends or patterns or used to improve the service as a whole.”
record keeping
2 findings
moderate“these medication records had not been audited as had been planned. This meant that there was a risk that medicines were not been given as prescribed.”
minor“Gaps and omissions in the recruitment practice or processes had not been identified through the quality monitoring system checks.”
consent capacity
2 findings
moderate“where people had been identified as lacking capacity there were no assessments available that detailed what decisions the person was unable to make.”
minor“In one instance a person's relatives had agreed to the care plan when they did not have the legal authority to do so.”
staff training
1 finding
moderate“Staff had not received training on MCA...training had not been provided in good dementia practice...staff did not have access to information about some healthcare conditions such as diabetes.”
staff competency
1 finding
moderate“The registered manager had no systems or processes in place to ensure that following receipt of training that staff had been assessed as competent.”
care planning
1 finding
moderate“when there was a change in a person's care needs these were not always clearly reflected in people's care plans and we found that some people's care plans did not contain up to date information.”
safeguarding
1 finding
critical“we found that we had not received one notification of a safeguarding concern that had been raised and investigated.”
incident learning
1 finding
moderate“Spot checks...had been recorded but actions and improvements resulting from them were not evident...no overall analysis of the spot checks.”