critical“There were not protocols in people's care records to provide instruction to staff on how to assess when people needed these medicines and how to administer them safely.”
critical“The providers medicines audits were not effective in identifying errors and discrepancies in people's medicines administration records (MARs).”
care planning
1 finding
critical“One person who was at risk of falls lived in a house which also had a swimming pool in the grounds. There was no risk assessment in the person's care plan.”
governance
1 finding
critical
“There was no overall action plan. This meant the provider did not maintain a sufficiently detailed oversight of the service and any improvements which needed to be made.”
staff training
1 finding
moderate“The provider's staff training matrix did not evidence if staff were up to date with their training or when refresher training was due.”
incident learning
1 finding
moderate“There was a lack of evidence to demonstrate the provider analysed accidents and incidents to identify trends and themes to prevent recurrences.”
safeguarding
1 finding
critical“Following an incident of abuse the provider had failed to conduct a sufficiently robust investigation to prevent a recurrence and safeguard people from harm.”
consent capacity
1 finding
moderate“There was a lack of evidence to show the provider had recorded people's consent to receiving care and support. None of the care plans we reviewed contained consent forms signed by people.”
record keeping
1 finding
moderate“The management team completed staff medicines competency assessments to identify areas for improvement. However, they told us they had not kept records of the assessments.”
person centred care
1 finding
minor“The provider had not sought any feedback from people about their views on the quality and suitability of care and support delivered.”