critical“one person had 51 gaps on their MAR in September 2022 for two topical creams and two topical spray medicines. Another person had 76 gaps in their MAR with no explanation”
care planning
1 finding
critical“Care plans did not contain enough information about people's specific medical conditions... no guidance for staff to follow should these people have an incident”
consent capacity
1 finding
critical“Some people had specific mental capacity assessments in place however, there were no best interest decisions recorded when a person was assessed as lacking capacity”
governance
1 finding
critical“Several audits were carried out, but these were not done in line with their policy because they were not completed effectively and did not drive improvement.”
staff training
1 finding
critical“Eight staff members who had been in post for over 4 months had not completed the Care Certificate... 1 staff member had completed a list of 33 different training subjects in 1 day”
supervision appraisal
1 finding
moderate“Staff did not receive supervision in line with the provider's policy... 'Staff have a supervision in the first month and then a supervision at 6 months in post'”
person centred care
1 finding
moderate“People were not always receiving person-centred care and support. People's care records sometimes lacked detail and did not fully capture their individual needs and wishes.”
communication with families
1 finding
moderate“They don't inform us if they are going to be late... If you ring the manager, they don't answer the phone. You have to chase the manager about things”
record keeping
1 finding
moderate“spelling mistakes, surname and address not correct... Access to care records shows lack of detail, so you do not get a comprehensive view of what has occurred during each visit”
incident learning
1 finding
moderate“When things went wrong, lessons were not always learnt to support improvement... improvements had not been sustained and the provider was found to be in breach of regulations.”
staff competency
1 finding
moderate“The registered manager told us staff received observations and competency assessments... however; they were unable to provide any evidence this took place.”