moderate“the systems in place had not been fully effective in assessing, monitoring and improving the quality and safety of the service.”
moderate“whilst a recruitment audit had been undertaken in December 2018, this had not identified and rectified the concerns our inspection found.”
staffing levels
1 finding
critical“one staff member did not have an enhanced criminal record check...All of the staff records viewed did not contain a full employment history.”
record keeping
1 finding
critical“References had been obtained but in some cases, these were telephone references that had not been confirmed in writing.”
care planning
1 finding
critical“one person was living with epilepsy. Their seizure escalation plan contained conflicted information...key staff were also not clear about the escalation plan.”
medication management
1 finding
critical“one person was prescribed a medicine to be taken every second day, this had not been happening. The prescribed dose was one or two tablets but staff were not recording how many were actually given.”
incident learning
1 finding
moderate“following such events such as falls or medicines errors, staff had not completed an incident form and there was no routine monitoring of incidents and accidents.”
supervision appraisal
1 finding
minor“we recommend that the registered manager ensure they have access to ongoing and regular clinical or professional supervision and that a suitable programme of mentorship is in place.”
end of life care
1 finding
minor“End of life care planning was also an area which could be further developed to ensure these provided a fully person centred record of people's known wishes and preferences.”