critical“Medicines were not handled safely or in line with the providers policy and best practice guidance. Records were not sufficiently completed to show people received their medicines as prescribed.”
critical“Some people were prescribed emergency first aid medicine for life threatening health conditions. These medicines were not recorded on the person's MAR and there was either no protocol for staff to follow.”
care planning
2 findings
critical“Care records did not include an assessment of people's needs and choices completed by the provider.”
critical“Where a person was at risk of choking and had experienced a recent incident of choking, there was no risk management plan to inform staff of the action they should take.”
governance
2 findings
critical“Governance systems and processes were either not in place or were not effectively operated to monitor the quality of the service, or to drive forward improvements.”
critical“Care plan audits did not take place. This meant opportunities were missed to identify where improvements were needed in risk management.”
staff training
2 findings
moderate“Staff training is not good, I have to train them. I'm not happy with their understanding of skin care and moving and handling skills.”
moderate“Most staff had not undertaken up to date safeguarding training.”
incident learning
1 finding
critical“A safeguarding incident had resulted in a person being hospitalised. The provider had failed to ensure that suitable risk management plans were implemented to reduce the risk of reoccurrence.”
staff competency
1 finding
critical“The registered manager and care co-ordinator confirmed to us that neither of them were qualified to deliver this training [moving and handling].”
consent capacity
1 finding
moderate“One person who had a legally appointed person acting on their behalf to make important decisions had no mental capacity assessment.”
safeguarding
1 finding
moderate“The registered manager had failed to always recognise what may constitute abuse.”
record keeping
1 finding
moderate“Reviews of people's assessed needs were not recorded which meant staff did not have up-to-date information about people's needs to ensure they received the right support.”
leadership
1 finding
critical“The provider and registered manager had failed to ensure they had sufficient oversight of the service to ensure regulatory compliance.”