Note26 Jul 2023
Recruitment processes were robust with DBS checks and references completed before employment.
Note26 Jul 2023
Service was working within the principles of the Mental Capacity Act with appropriate DoLS authorisations in place.
Note26 Jul 2023
Staff supervision frequency was increased following staff survey feedback.
Note26 Jul 2023
Non-medicines audits (cleanliness, falls, nutrition) were effective and driving improvements.
Note26 Jul 2023
Manager engaged collaboratively with health and social care professionals, including optician visits and fire safety improvements.
Note26 Jul 2023
Infection prevention and control measures were assured across all domains including PPE, admissions and outbreak management.
Note26 Jul 2023
Staff received safeguarding training and were confident in reporting and escalating concerns.
Note26 Jul 2023
Sufficient staffing levels maintained even below full occupancy due to increased needs post-COVID-19.
Note26 Jul 2023
Risks to people had been identified and care was planned to keep people safe, including appropriate equipment and staffing for moving and handling.
moderaterecord_keeping26 Jul 2023
Fluid intake was not well recorded meaning we could not be sure people were being offered enough to drink.
moderateincident_learning26 Jul 2023
There was no ongoing analysis to identify if there were any trends in the incidents. This meant opportunities to improve care could be missed.
criticalgovernance26 Jul 2023
Audits to identify issues with medicines were not effective for the last three inspections. This was a breach of regulation 17(1).
moderatemedication_management26 Jul 2023
Protocols were not always in place to ensure staff had the guidance needed to offer these medicines to people consistently when they needed them.
criticalmedication_management26 Jul 2023
Medicines records did not accurately record when medicines were administered and how many were left in the home.
criticalmedication_management26 Jul 2023
One staff member who was administering medicines had not had their competency checked within the previous 12 months.