critical“one person required topical cream applied twice daily, records showed this was applied 4 times each day. Records did not provide any direction for staff on where creams were to be applied.”
staffing levels
1 finding
moderate“Some staff were rostered to work an excessive number of hours with appropriate breaks.”
staff training
1 finding
moderate“Training records showed a number of staff had completed multiple courses in 1 day. This did not demonstrate training was appropriately planned to promoted staff learning.”
staff competency
1 finding
critical“Medication competency assessments were completed for staff as part of the induction programme. Records seen showed assessments of staff had been carried out with people who did not receive support with the medicines.”
governance
1 finding
critical“The service did not have systems in place to monitor and review the service provided. The office environment was disorganised and did not provide an effective working environment.”
record keeping
1 finding
moderate“Both electronic and paper records were inaccurate and incomplete.”
consent capacity
1 finding
critical“Where people were said to lack capacity to make their own decisions, an MCA assessment had not been completed. Information was not sufficiently detailed where decisions had been made in their 'best interest'.”
care planning
1 finding
critical“Specific areas of concern, such as behaviours that challenge and self-harm had not been thoroughly assessed and planned to provide clear guidance for staff.”
supervision appraisal
1 finding
moderate“Self assessments and observed competency assessments had been completed with some staff. Where additional learning had been identified there was no evidence this had been acted upon.”