critical“A person who had epilepsy was not given their emergency medicine in line with their protocol. The seizure had not been recorded in the person seizure records.”
safeguarding
1 finding
critical“Not all incidents had been identified and reported to the local authority safeguarding team.”
incident learning
1 finding
critical“Choking incidents had not been reported. A person was documented within the communication book as having choked, however there was no incident form.”
care planning
1 finding
moderate“The care plans need reviewing, people's needs have changed since they were put in. They are not great, not easy to follow.”
governance
1 finding
critical“Audits and spot checks that should have been completed by the registered manager and the management team had not been.”
staffing levels
1 finding
critical“Staff who worked at one of the clusters had not been trained to administer emergency epilepsy medicine where there was an identified need.”
consent capacity
1 finding
critical“People with sensors or monitors in their bedrooms did not have capacity assessments or best interest decisions.”
person centred care
1 finding
moderate“A person's documentation stated they 'must be sent to their room as they can upset other residents and staff.'”
staff competency
1 finding
critical“An agency staff member we spoke with was unaware of rescue medicines people within their cluster needed.”
record keeping
1 finding
moderate“Some liquid medicines and creams did not have an open date on the bottles to ensure the medicines were discarded after a certain time period.”
communication with families
1 finding
minor“People were not involved in care planning or setting goals or aspirations.”
leadership
1 finding
moderate“Only 35% of staff said they would recommend HF Trust - Kent DCA as a great place to work.”