critical“MARs did not provide clear information about how to administer people's medication, including route or time of administration. Staff were not completing records in full.”
governance
1 finding
critical“Quality assurance arrangements were not always applied consistently and were ineffective. The provider carried out audits of MARs and staff files however, we found these did not highlight concerns.”
record keeping
1 finding
moderate“Care plans and daily records lacked detail and legibility. Records for people with nutritional needs did not always include specific information required around fluid intake.”
missed or late visits
1 finding
moderate“There were concerns with staff arriving late. We were not assured people always received their care on time.”
staff training
1 finding
moderate“We could not be assured the service had oversight of specialist training completion or renewal. Certificates of completion were not available for specific training such as PEG or catheter care.”
consent capacity
1 finding
moderate“The service was not always working within the principles of the MCA. The registered manager had carried out some capacity assessments where relevant however, this was not the case for all people.”
care planning
1 finding
minor“Care records were not always written in a person-centred way. Some records used generic statements to describe people's goals and objectives.”
staff competency
1 finding
moderate“Staff recruitment checks were not always carried out in full. We found gaps in employment history were not always explained prior to appointment.”