critical“Medicines were not always managed and administered safely. The electronic medicines management system used by staff had been inoperable for several weeks.”
care planning
1 finding
critical“1 person had been prescribed a modified diet and fluids by a speech and language therapist…there was no risk management plan in this person's care plan to ensure staff understood the risks.”
governance
1 finding
critical“Some audits were in place; however, they had not identified the concerns found during this inspection. Further audits were required to ensure a full and robust oversight.”
record keeping
1 finding
moderate“Accurate, complete and contemporaneous records were not always kept for people. For example, daily notes were not always detailed.”
consent capacity
1 finding
moderate“Some staff we spoke with had limited understanding of MCA and told us they would refer decisions to family members if a person was not able to consent.”
staffing levels
1 finding
moderate“People told us they did not always get their calls on time from consistent staff or staff of their preferred gender.”
communication with families
1 finding
minor“Some people, relatives and staff raised concerns with us about language barriers with some care staff and felt that this was a risk to providing safe care.”
person centred care
1 finding
minor“Some people, relatives and staff raised concerns with us about not always receiving care from same gender carers only, when this is their stated preference.”