minor“staff had failed to record administration using their initials and had ticked to demonstrate medicines had been taken by people”
critical“The management and administration of medicines was unsafe. The provider's medicine procedure was not in line with current legislation and guidance.”
moderate“Staff did not complete medicine administration records (MAR) correctly. One person's MARs only had a tick against the medicine administered instead of a staff signature”
other
3 findings
critical“Three staff files checked did not contain references in line with legislation and best practice guidance. The registered manager confirmed they did not check references”
moderate
“Employment histories were not always checked to ascertain the reason for gaps within individual's employment history.”
critical“Risks to people were not effectively managed putting them at risk of harm... the risk associated with this condition had not been assessed and there was no guidance for staff”
care planning
2 findings
critical“People's care plans were not personalised to their needs One person's care plan did not have information relating to their medical health need.”
critical“There was no care plan or guidance in place covering the process to follow on how to manage this effectively (PEG tube)”
staff competency
2 findings
critical“The registered manager had not assessed staff competency to ensure they could perform this task safely.”
moderate“Records showed staff had attended medicine administration training. However, the registered manager had not checked or assessed their competency.”
governance
2 findings
critical“The provider and registered manager had failed to operate systems to assess, monitor and improve the quality of the service provided.”
moderate“The quality of documentation and policies for managing the service did not meet current legislation and guidance.”
leadership
1 finding
critical“The registered manager lacked oversight of the service delivered, thereby putting people at risk of unsafe care.”
person centred care
1 finding
critical“Care was not planned and tailored to people's individual needs”
complaints handling
1 finding
minor“The complaint procedure did not provide information on the stages of the complaint procedure and contacts of independent reviewing authorities”
communication with families
1 finding
moderate“communication with staff and people may not always be effective as staff had been carrying out some care and support tasks which the registered manager had told us they were not doing.”