moderate“more time was required to ensure these new processes and audits identified risks and incidents were actioned appropriately.”
critical“The provider failed to put reliable and effective monitoring systems in place to ensure there was good oversight of the service in relation to care planning, risk management.”
leadership
2 findings
minor“the registered manager was working to develop open and trusting relationships with other professional such as the local authority and healthcare professional and more time was needed”
critical“The provider did not understand the principles of good quality care and had not developed systems and processes to ensure compliance with regulations.”
person centred care
2 findings
minor“More time was needed to fully reflect and evaluate on whether people's experience and care provided supported them to meet their goals.”
moderate“The culture was not consistently person centred and the provider did not record outcomes for people.”
communication with families
1 finding
minor“more time was required to allow the provider to demonstrate they were able to act on people's feedback and maintain standards going forward.”
medication management
1 finding
critical“Staff administered medicines to people they had not prepared or dispensed. Staff signed records to show medicines had been administered at times they were not present at people homes.”
care planning
1 finding
critical“Where people needed supported with oxygen therapy and equipment such as a ventilator, there was no guidance for staff on how to support with this equipment.”
staff training
1 finding
critical“Only 45% of staff had received training in epilepsy and 54% in pressure area care. This placed people at ongoing risk of harm.”
staff competency
1 finding
critical“Competency checks for staff on administering medicines had been completed by a staff member who had not received additional training to complete this task.”
safeguarding
1 finding
critical“Lack of training for staff, and the absence of comprehensive risk assessments and person centred care plans placed people at risk of avoidable harm.”
record keeping
1 finding
critical“Gaps were identified in MAR charts. Staff had not recorded why these medicines had been administered and audits had failed to identify these gaps.”
incident learning
1 finding
moderate“We found no action had been taken to embed a culture of learning lessons from previous incidents.”