critical“People's MAR charts did not indicate what the medicines were prescribed for, the side effects experienced by people and the times the medicines were due.”
critical“The provider failed to have a system to monitor the safety of the medicines management; they failed to identify the missing information or potential medicines errors.”
staff training
2 findings
critical“Not all staff had received training and refresher training in medicines management, catheter care and epilepsy.”
moderate“Not all staff had received training or refresher training in first aid, fire safety, challenging behaviour, control of substances hazardous to health, safeguarding, moving and handling.”
person centred care
2 findings
moderate“People's protected characteristics under the Equality Act 2010 including age, disability, gender reassignment and religion had not been recorded.”
moderate“The provider failed to have systems to provide accessible information to support people to understand and be involved in the planning of their holidays.”
care planning
1 finding
critical“People did not have care plans or behavioural support plans for staff to refer to. Staff did not have the information they needed to always know how to provide safe care.”
record keeping
1 finding
moderate“Staff did not record daily notes to demonstrate people received their care as planned.”
consent capacity
1 finding
critical“The provider did not have systems in place to ensure all mental capacity assessments had been recorded, or systems to arrange for best interest decisions.”
governance
1 finding
critical“The provider failed to have adequate systems to assess, monitor and mitigate the risks of people's health, safety and personal care needs. This was a breach of regulation 17 (2).”
staffing levels
1 finding
moderate“There was no system to calculate the number of staff required on each holiday. There was no provision for staff breaks or contingency for managing people's care.”
incident learning
1 finding
moderate“There were not enough systems in place to record and analyse the planning, risk assessment and outcome of the care received by people during their holidays.”
communication with families
1 finding
moderate“People's communication needs were not recorded; staff and emergency services did not have all the information they needed to communicate effectively with people.”