critical“medication had been administered incorrectly by untrained staff, errors where people had missed medication which could cause a risk of harm when not taken and occasions appropriate advice was not sought”
governance
1 finding
critical“audits were identifying shortfalls, gaps and errors in practice however the outcomes and scoring system from audits recorded in most cases a '100%' compliance score”
record keeping
1 finding
critical“Areas where we found inconsistencies, gaps and an absence of checks included health and safety records, people's care records, finance checks, daily notes, medication records”
incident learning
1 finding
critical“accidents and incidents had occurred within supported settings they weren't always reported on the system and some staff stated they weren't always recorded at all”
care planning
1 finding
moderate“some care plans contained language which was negative and needed updating. Other care plans needed further detail to accurately reflect the support people needed”
staff training
1 finding
moderate“Compliance with training was significantly low in some areas. However, the provider evidenced the cause for this in some areas was related to staff turnover”
staffing levels
1 finding
moderate“frequent use of agency staff to meet the staffing levels allocated to people's support and care... impacted people being supported by staff who knew them well”
person centred care
1 finding
moderate“people's choices were limited, particularly in relation to activities... people's goals and aspirations had not been met and some people were only able to access the community in the form of 'going for a drive out'”