moderate“the provider had not completed protocols and guidance for 'as required' prescribed creams as they had not recognised this as an 'as required' medicine.”
critical“Medication Administration Records (MAR) should specify the details of when prescribed creams should be applied... We found prescribed creams were not detailed on people's MAR charts.”
care planning
2 findings
moderate“the risk of bed rails to one person had not been fully considered. In addition, risk assessments around healthcare conditions such as diabetes needed to become more focussed on the individual person's needs”
critical“The provider did not have clear care plans or risk assessments in place which detailed the support people required.”
staff training
2 findings
moderate“Staff had not received training around the Mental Capacity Act 2005.”
critical“One staff member had not received any training, from the provider, at all.”
staff competency
2 findings
moderate“Following training there was no formal competency sign off and whilst some areas of care had a competency assessment, others did not.”
critical“medication training had not taken place for all staff or that staff competency had not been monitored and assessed in line with their own policies.”
supervision appraisal
2 findings
critical“there was no record of staff supervisions that had taken place... informal supervision took place but that this was not recorded.”
moderate“The provider was unable to provide us with staff supervisions or meeting minutes as they had not kept written evidence of the discussions which had taken place.”
governance
2 findings
critical“the systems to monitor the quality and safety of the service had failed to identify these areas of concern. This was a continued breach of Regulation 17 (Good Governance)”
critical“Quality assurance systems were inadequate. Potential risk and areas of improvement were not identified.”
record keeping
2 findings
moderate“Audits had not identified that some review dates for documents had passed.”
critical“Some records were not available when requested at the time of the inspection at the office. This was due to documents such as care plans and risk assessments not being in place.”
consent capacity
2 findings
minor“Staff had not received training around the Mental Capacity Act 2005.”
moderate“Staff had not received training in people's rights under the MCA and when to act in their best interests to ensure peoples safety and welfare is maintained.”
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.”
infection control
1 finding
moderate“Records did not show that care staff members had received training in the correct use of Personal Protective Equipment (PPE)... Just one care staff member had received infection and prevention training.”
end of life care
1 finding
minor“Care plans did not incorporate advanced decisions or end of life planning. Staff had not received training in EOL care.”
other
1 finding
critical“Suitable references had not been obtained prior to care staff members commencing work... the provider had not received an up to date criminal records checks clearance, prior to care staff commencing employment.”