critical“No recording of 1 person's medicines administration took place and at the time of inspection staff administered their medicines 3 times per day.”
critical“One person was prescribed morphine, a strong pain killer, but there was no guidance for staff to ensure it was given correctly and safely.”
critical“MARs submitted to CQC did not detail the level of support a person required or the role of staff. This meant we could not be sure the medicine had been administered safely.”
critical“Information in relation to allergies was also missing from the MARs. The provider's own policy stated the records must be written clearly, with known allergies identified.”
governance
2 findings
critical
“Under this provider, this is the fifth occasion a rating of 'Inadequate' has been awarded in the key question of 'well-led' since 2019.”
critical“Systems and processes had not been operated to ensure robust governance and oversight of the service. This was a breach of Regulation 17 (1).”
incident learning
2 findings
critical“Accident and incident reporting processes were not always effective. There was no record of some incidents.”
moderate“The process for the reporting and the following up of accidents or incidents was not always clear...actions taken and follow up actions were not being recorded on these.”
consent capacity
2 findings
critical“Documentation put in place was not completed fully or effectively...People remained at risk of having decisions made which were not in their best interests.”
critical“We could not be assured that a best interest decision had been taken or that an MCA assessment was in place for the use of bedrails at night for a person whose capacity fluctuated.”
record keeping
2 findings
critical“MAR being completed on days which didn't exist, for example 29th to 31 February, or being signed by staff who were different to those on shift.”
moderate“One person's moving and handling risk assessment stated the person was independent on one page, when in fact the person was unable to mobilise independently.”
leadership
2 findings
moderate“The registered manager was also the nominated individual and provider...there were no other persons involved or accountable for strengthening the oversight.”
moderate“The registered manager, who was also the provider told us they had been focusing on providing hands on care to people...This had led to a lack of oversight of the service.”
safeguarding
1 finding
critical“Due to a miscommunication care staff had not visited to support a person with their morning routine...but the local authority were not notified.”
care planning
1 finding
critical“Some people were at increased risk of choking, pressure wounds or falls and there were no risk assessments in place.”
staff training
1 finding
moderate“Records of staff training contained gaps and were undated so there was no easy reference system to know whether training remained in date or had lapsed.”
person centred care
1 finding
moderate“People's care records did not contain detailed information about their routines, needs and day to day preferences.”
supervision appraisal
1 finding
minor“Staff had received supervision, though this had been sporadic. The registered manager said there was only a small number of staff and they all worked together.”