critical“Risk management plans...did not always identify guidance for all risks related to people's care or provide enough information for staff on how to mitigate the risks.”
critical“The provider had not developed personal emergency evacuation plans (PEEPS) for people who were being supported.”
moderate“The care plan for 1 person whose support needs had increased did not reflect their new care needs...food intake was not recorded or monitored.”
medication management
2 findings
critical“People were being given homely remedies...no record of the use of these over-the-counter medicines had been checked with a GP to ensure there were no risks of interaction.”
critical
“Training records showed that not all staff had completed training on administration of medicines.”
incident learning
2 findings
critical“There was no analysis of the reasons for the incident and accident and what could be done to limit the risk of reoccurrence.”
critical“The register manager confirmed that not all incidents were recorded...if an incident occurred between people they were supporting, it was not always recorded.”
governance
2 findings
moderate“An audit was carried out on care plans every 3 months to check if the documents were in place but not if the information in the documents was accurate or person centred.”
moderate“The registered manager did not always inform the Care Quality Commission when a notifiable incident occurred.”
safeguarding
1 finding
critical“There were no records of improvements being identified and learning put in place following the outcome of the safeguarding.”
infection control
1 finding
critical“2 other staff members could not explain how they managed infection control...the provider did not have processes in place to ensure that infection control procedures were always followed.”
person centred care
1 finding
moderate“Care plans were not accessible for people...the format was more designed for providing staff with information and not the person receiving the support.”
complaints handling
1 finding
moderate“The provider had information about complaints...but had not undertaken an investigation which identified any actions which could be implemented to reduce further risk.”
record keeping
1 finding
moderate“Records completed by staff were not always contemporaneous...limited information on any activities carried out with staff or what the person had done during the day.”
consent capacity
1 finding
moderate“There was no explanation as to how the information was shared with the person based upon their communication needs...unclear how the care was explained to enable the person to understand and consent.”
staffing levels
1 finding
minor“There was no procedure to explain what would happen if more than 1 person required a staff member to accompany them.”
staff competency
1 finding
critical“The registered manager confirmed that medicines competency assessments to monitor staff member's understanding and skills in administering medicines [were not completed].”