critical“Some staff started working before their Disclosure and Barring Service (DBS) checks had been received.”
staff competency
1 finding
critical“The provider had failed to operate robust recruitment procedures, including undertaking any relevant checks.”
medication management
1 finding
critical“gaps in medication administration records (MAR), suggesting people may have missed doses of critical medication for example, anticonvulsant medicine”
governance
1 finding
critical
“This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2018 (Regulated Activities) Regulations 2014.”
care planning
1 finding
moderate“People's care plans and risk assessments were not always regularly reviewed and updated.”
staff training
1 finding
moderate“five staff had not completed first aid training and four staff had not had any medication administration training.”
supervision appraisal
1 finding
moderate“Staff did not have regular supervision, to receive feedback on their performance and constructive feedback on how this might be improved.”
incident learning
1 finding
moderate“the provider did not keep a record of the types or frequency of these reports, to enable them to look for patterns or trends”
person centred care
1 finding
moderate“Most people told us they were not aware of the content of their care plan and did not have a copy.”
complaints handling
1 finding
moderate“the provider told us they had no records of these complaints.”
infection control
1 finding
minor“staff did not always wear the appropriate PPE when supporting them. Not all staff had received infection prevention and control (IPC) training.”
record keeping
1 finding
moderate“records could be stored in different formats including paper and the computerised system, making it difficult to get an overview quickly of people's care”
communication with families
1 finding
minor“The provider did not have a clear understanding of, and so had not applied, the principles of the Accessible Information Standard”