critical“The provider failed to ensure systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.”
care planning
1 finding
critical“Risk assessments were inadequate. Key risk concerns for the person were not explored or reduced in their individual risk assessment.”
infection control
1 finding
critical“Staff testing for COVID-19 and use of PPE were not in line with government guidance.”
medication management
1 finding
moderate
“The provider was not able to evidence the MARs were being checked or audited to ensure the person was receiving their medication safely or appropriately.”
staff training
1 finding
moderate“The provider was not able to demonstrate all staff had received the training they needed to fully and safely support the person.”
staff competency
1 finding
moderate“Competency checks were not being regularly completed to ensure staff skills were effective.”
supervision appraisal
1 finding
moderate“Supervision had not been offered to staff regularly, the provider had explained this was due to difficulties in recruiting a manager”
consent capacity
1 finding
moderate“The person's risk assessment indicated there was a need for a mental capacity assessment, but one had not been initiated.”
person centred care
1 finding
moderate“Language used by staff was not always respectful, for example, staff referred to the person's home as 'a unit.'”
record keeping
1 finding
moderate“A document designed to be shared with medical staff in the event of an emergency contained incorrect information about medicines.”
leadership
1 finding
moderate“Since June 2020 there had been four consecutive changes of management.”
incident learning
1 finding
moderate“The provider had not established systems to audit and check safety and quality effectively, this meant learning opportunities would be missed”