moderate“Their care plan noted this was a prescribed medicine, however we found no medicine administration record (MAR) was in place.”
record keeping
1 finding
moderate“Some MAR records were not completed in line with best practice guidance. For example, MAR records did not include the person's date of birth.”
care planning
1 finding
moderate“We also identified the absence of a robust risk assessment in relation to one person's use of bed rails and the absence of risk assessments in relation to one person's diagnosis of diabetes”
infection control
1 finding
moderate“Staff feedback and records showed uptake of weekly COVID-19 PCR tests had been variable.”
safeguarding
1 finding
minor“The policy, which included guidance about recognising signs of abuse, and staff handbook did not include self-neglect and modern slavery.”
governance
1 finding
moderate“audits had failed to identify all of the concerns we found in relation to risk assessments and medicine records.”
staff competency
1 finding
minor“The service did not have formal observational competency assessments documented in areas such as medicines administration and infection control.”
supervision appraisal
1 finding
minor“One staff member's supervision record showed a gap in sessions between March 2021 and September 2021.”
staff training
1 finding
minor“two members of staff employed since February and May 2021 had not completed the Care Certificate.”
consent capacity
1 finding
minor“We recommend the service monitors and reviews their processes for seeking consent, to ensure records fully reflect how people have been consulted in relation to their care”
incident learning
1 finding
minor“Accidents and incidents were documented inconsistently. Some incidents had been logged onto an incident form... Other incidents had been logged onto communication sheets”
end of life care
1 finding
minor“training records identified four care workers had not received end of life care training, including one recent new starter.”