critical“There was no effective oversight of the management of 'as required' (PRN) medication. One person had received their 'as required' medicines daily, without clear rationale as to why this was the case.”
governance
1 finding
critical“Systems in place to monitor the quality of care people received were not robust and had not identified areas of potential risk which were found on this inspection.”
record keeping
1 finding
moderate“The information recorded in people's care records and risk assessments was not always accurate, up to date and complete.”
safeguarding
1 finding
critical“The provider had not always notified the relevant external agencies of potential abuse concerns or made these notifications in the correct manner.”
care planning
1 finding
moderate“One person's care plan advised staff to 'use strategies that had worked in the past' when supporting a person, but no information had been provided to staff to advise what those strategies were.”
staff training
1 finding
moderate“The training overview showed staff had completed all of their mandatory online training, including moving and handling training, on a single day.”
supervision appraisal
1 finding
moderate“Formal supervisions had not taken place as per the provider's own protocol [every 3 months].”
incident learning
1 finding
moderate“The provider had not conducted overall analysis of these events to identify themes and trends and reduce the risk of reoccurrence.”
consent capacity
1 finding
moderate“Care records failed to demonstrate people's capacity to make decisions for themselves and the provider had failed to obtain copy of Court of Protection documents in respect of one service user.”