critical“A person had not received 1 medicine for at least 11 days due to running out of stock. This had not been identified by the service and no actions had been taken.”
critical“MAR did not always include the date of administration, the prescriber's instructions for how and when the medicine should be taken and which route the medicine should be administered.”
care planning
1 finding
moderate“The care plans have been terrible and some years out of date, no information at all, we have been blind. They are slowly being sorted out.”
consent capacity
1 finding
critical
“5 out of the 6 care plans we reviewed did not have a signed consent to care in place. Where people lacked capacity, mental capacity assessments had not been completed.”
staff training
1 finding
critical“I had no experience of mobility aids/hoists, hazards and risks yet I was expected to care with no training in place at all.”
supervision appraisal
1 finding
moderate“Staff told us they felt supported however, they had not received regular supervisions and appraisals.”
staff competency
1 finding
critical“Staff had not always been assessed as competent to administer medicines. At the time of our inspection, 2 out of 13 staff had been assessed.”
incident learning
1 finding
moderate“The nominated individual told us there had not been a lessons learned process in place and they were working to establish a system to ensure learning in the future.”
governance
1 finding
critical“Governance systems and processes were either not in place or effective at identifying areas of improvement. This meant quality performance had not always been assessed.”
record keeping
1 finding
moderate“Risk assessments had not been completed to assess people's susceptibility to infections and any potential risk of harm from their environments.”
safeguarding
1 finding
critical“Incidents that affected the health, safety and welfare of people using the service had not always been reported internally and to the relevant external authorities/bodies.”