critical“Two incidents, including unexplained bruising, which had not been followed up by the provider or reported to the local authority.”
critical“One staff member told us they would tell the adult that any conversation about safeguarding was 'between the two of us' and would not report safeguarding concerns unless the adult agreed.”
medication management
1 finding
critical“Medicine management was not consistently safe. MAR contained gaps and some records were not accurate and did not reflect the person's current prescribed medicines.”
governance
1 finding
critical
“Systems in place to audit the service had failed to identify and address medicine errors. There were no auditing systems in place to identify trends and reduce risk.”
record keeping
1 finding
critical“People's hospital grab sheets omitted important information such as one person's medication allergies and another person's health condition.”
care planning
1 finding
moderate“Care plans did not always contain personalised information such as people's hobbies and religion. There was no effective system to ensure care plans provided sufficient guidance.”
consent capacity
1 finding
moderate“Consent forms had been signed by a family member when they did not have the legal authority to do so. Decision specific capacity assessments or best interests decisions not recorded.”
incident learning
1 finding
moderate“Although action was taken, we identified ongoing concerns and further learning and action was required following a complaint with regards to medication administration.”
person centred care
1 finding
moderate“Personalised support was not always given. A relative told us, 'I have to stay on top of things, it's the little things.'”
staff competency
1 finding
moderate“Staff received training from an external training provider, however we found that staff did not always put their training into practice, such as regarding medication.”