critical“Safeguarding training for all staff, including the registered manager, was out of date.”
critical“Some people had a Do Not Attempt Resuscitation order in place but their care records incorrectly stated they did want to be resuscitated.”
medication management
2 findings
critical“Staff did not complete medication administration records (MAR) charts when they applied prescribed cream.”
critical“Not all staff supporting people with their medicines had done medicines training.”
care planning
1 finding
critical“Some people did not have care plans in place and some people's care plans had not been reviewed and updated when their needs had changed.”
staff training
1 finding
critical“All staff training was out of date and two members of staff had not done any training in how to provide care.”
staff competency
1 finding
critical“some staff were not suitably competent and skilled to provide people with safe care.”
supervision appraisal
1 finding
critical“Staff supervision had not taken place on a regular basis for all staff and the provider had not ensured all members of staff could attend staff meetings.”
staffing levels
1 finding
moderate“The registered manager was providing care calls to people. It was evident the amount of care calls the registered manager was providing meant they did not have sufficient time to focus on the management of the service.”
governance
1 finding
critical“The provider's governance of the service was inadequate and had not identified the issues we found at our inspection.”
leadership
1 finding
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
incident learning
1 finding
moderate“the forms used to record incidents when people had been distressed did not contain any analysis of events or state what actions could or should been taken in the future to prevent them from recurring.”
infection control
1 finding
critical“There were no individual Covid-19 risk assessments for people or staff. This meant the provider's IPC practice was not in line with government guidance for safe Covid-19 IPC practice”
record keeping
1 finding
moderate“Some people's daily notes contained insufficient information when staff had applied cream to a person. Staff had only written 'creamed' in the person's notes.”
person centred care
1 finding
moderate“People's care records lacked personalised and person-centred information about people. Some people did not have care plans in place.”
end of life care
1 finding
moderate“People's end of life care plans did not always contain personalised information about how staff should provide them with personal care during the end of their life.”
cultural competency
1 finding
moderate“On a number of occasions staff had written the word "tantrums" when describing a person's behaviour.”
other
1 finding
critical“We did not see evidence the provider had carried out Disclosure and Barring Service (DBS) checks for new staff.”