critical“Some people did not have risk assessments in place for specific health conditions such as Parkinson's Disease and Dementia.”
moderate“Some care plans were not always reflective of people's needs...discrepancies in information recorded around people's care needs, to what staff were providing.”
critical“Care plans were often generic and often contained information regarding other people. This meant that new staff would have difficulty delivering personalised care.”
medication management
2 findings
critical“Medicine Administration Records (MARs) were not always completed which did not provide assurances people always received the medicines they were prescribed.”
critical
“Medicine records did not contain accurate information. We saw one person's medicine record had been signed for by the same staff member for the whole month. However...the staff member had not provided care.”
governance
2 findings
critical“Audits were completed but not always accurately which meant concerns and issues were not identified in a timely manner.”
critical“No quality audits had been completed to ensure care was safe and effective...A lack of quality oversight meant the provider had failed to monitor and improve the quality and safety.”
record keeping
2 findings
moderate“Accidents and incidents were kept in two different places which meant the monitoring audit completed did not contain all incidents that had occurred.”
moderate“Staff did not keep clear records of the actual times spent with people so the provider could not demonstrate people received their care visits in a timely manner.”
consent capacity
2 findings
moderate“Mental capacity assessments had not been completed for people...we could not assess if good practice was fully embedded at the service.”
moderate“One person's mental capacity assessment...was not for a specific decision and referenced decisions relating to multiple areas...also contained contradictory information.”
incident learning
2 findings
minor“There was a lack of notifications submitted which meant full assurances around embedded practice was not obtained during this inspection.”
critical“The provider did not have a system to record accidents and incidents and no system to monitor and review for trends and to learn lessons when things had gone wrong.”
safeguarding
1 finding
critical“As a result of our inspection, we made three referrals to the local safeguarding board. The provider's systems...had not followed local safeguarding protocols.”
staff training
1 finding
critical“Staff had limited knowledge on how to meet some people's care needs...the provider could not evidence that this training had been completed.”
staff competency
1 finding
moderate“The provider failed to complete competency checks for staff to ensure staff knowledge and practice was in line with current standards.”
leadership
1 finding
critical“The registered manager and nominated individual did not have clear oversight of the service. They had not identified the shortfalls we found on this inspection.”
person centred care
1 finding
moderate“People's individual likes and preferences were not always recorded in their care plans and associated risk assessments. This meant new staff would be unclear on how best to support people.”
supervision appraisal
1 finding
moderate“The registered manager failed to complete staff supervision and carry out competency checks in a timely manner. Staff were unclear about how they were performing within their role.”
infection control
1 finding
minor“We were not assured that the provider's infection prevention and control policy was up to date. The isolation information contained within it has been replaced by alternative guidance.”