critical“the provider had failed to ensure areas for improvement were identified and action was taken in a timely manner. This was a breach of regulation 17 (Good governance)”
critical“The provider's governance systems had failed to identify that the recruitment procedure had not always been followed and action had not been taken to request missing information.”
critical“The provider did not have adequate oversight of the service to ensure that people were provided with a high-quality, safe service.”
medication management
2 findings
critical“the provider had failed to ensure that people received their medicines as prescribed. This was a breach of regulation 12 (Safe Care and Treatment)”
critical
“Staff still had not received training and competency assessments before administering medicines to people unsupervised. This meant that people may not receive their medicines as prescribed.”
staff competency
2 findings
critical“the provider had failed to ensure staff were recruited safely and they had the right knowledge and skills to meet people's needs. This was a breach of regulation 19”
critical“For the three members of staff who had been employed since the previous inspection; the registered manager was not able to produce a medication competency assessment however they were administering medicines unsupervised.”
staff training
2 findings
critical“Staff were not completing their induction, core training and competency assessments as set by the provider before working with people unsupervised.”
moderate“the registered manager told us they received their last training in August 2017, 15 months earlier. This meant they may not be up to date with legislation and best practice.”
record keeping
2 findings
moderate“Handwritten entries to the medicine charts had not included the name of the person making the entry and it had not been countersigned by another member of staff.”
moderate“people's care plans did not consistently record these. This meant that if new staff provided people's care, they would not have sufficient guidance.”
leadership
2 findings
critical“Although the areas for improvement had been identified during previous inspections and discussed with the registered manager, action had still not been taken to make all of the required improvements.”
moderate“there was no-one else involved in running the service and there was no other oversight of the registered manager's practice.”
safeguarding
2 findings
critical“New staff had sometimes been employed before all of their recruitment checks were returned. Care staff had been employed before their criminal records checked were returned and were working alone.”
minor“the registered manager stated that they were in the process of putting together an emergency evacuation plan for someone they provided 24 hour care”
care planning
2 findings
moderate“one person's care plan contained no information about the continence aid they used or the aids they used to help them drink independently.”
minor“The care plans would benefit from being more detailed so that any new staff are aware of people's preferences.”
consent capacity
1 finding
critical“Where people did not have the mental capacity to make decisions, processes had not have been followed to protect people from unlawful restriction and unlawful decision making.”