minor“more detailed information was still required [for 'as and when required' medicines]. The registered manager addressed this immediately by completing new forms.”
critical“Guidance for staff to follow when administering as and when required medicines was not always available.”
critical“People's records were not always clear as to whether their medicines were prompted or administered by staff.”
record keeping
2 findings
moderate“we found 1 occasion where written records of an interview were not kept, and sometimes only 1 reference instead of 2 were obtained.”
moderate
“We found some documentation in care plans and risk assessments was not always completed in full.”
missed or late visits
2 findings
minor“some people told us that occasionally staff did not stay for the correct length of time. The registered manager had commenced electric monitoring of this.”
moderate“One person said, 'The visit times vary.' Another person told us, 'Sometimes they are half an hour early, which is not convenient.'”
incident learning
2 findings
minor“There was an incident recording policy however more detail was required, which the registered manager confirmed would be addressed.”
moderate“They were not consistently monitored to identify lessons learned, themes or trends.”
governance
2 findings
critical“The provider had failed to make sure there were effective systems in place to monitor risk and performance of the service. Breach of regulation 17(1).”
moderate“Questionnaires about the service performance and quality were gathered from staff, relatives and people using the service. However, they were not analysed.”
staff competency
1 finding
moderate“on some occasions the registered manager relied on DBS checks from previous employment. CQC guidance states there should be a new DBS check within 3 months.”
care planning
1 finding
critical“Assessment records did not always provide a detailed plan for managing the risks...not fully reassured that measures were in place to manage risks associated with diabetes, moving and handling.”
safeguarding
1 finding
critical“Not all incidents and allegations had been notified, as legally required, to us.”
staffing levels
1 finding
moderate“One member of staff said, 'Sometimes the times where you next have to be coincided with the time you're leaving someone, so no time allocated for travelling.'”