Note22 Mar 2024
Where prescribed medicines were in use, MAR records were completed with name, form, frequency and administration timing.
Note22 Mar 2024
Staff felt supported by the provider, with monthly supervision and staff meetings in place.
Note22 Mar 2024
The provider worked closely with the local authority and healthcare professionals to provide care packages.
Note22 Mar 2024
People's cultural and religious preferences were identified and respected, including diet reflecting religious preferences.
Note22 Mar 2024
People were supported to access their religious community, visit friends and family, and go shopping with staff support when requested.
Note22 Mar 2024
Provider had a recruitment process enabling identification of new staff with required skills, including right-to-work checks, two references and DBS checks.
criticalstaff_competency22 Mar 2024
The registered manager confirmed that medicines competency assessments to monitor staff member's understanding and skills in administering medicines [were not completed].
minorstaffing_levels22 Mar 2024
There was no procedure to explain what would happen if more than 1 person required a staff member to accompany them.
moderateconsent_capacity22 Mar 2024
There was no explanation as to how the information was shared with the person based upon their communication needs...unclear how the care was explained to enable the person to understand and consent.
moderaterecord_keeping22 Mar 2024
Records completed by staff were not always contemporaneous...limited information on any activities carried out with staff or what the person had done during the day.
moderategovernance22 Mar 2024
The registered manager did not always inform the Care Quality Commission when a notifiable incident occurred.
moderategovernance22 Mar 2024
An audit was carried out on care plans every 3 months to check if the documents were in place but not if the information in the documents was accurate or person centred.
moderatecomplaints_handling22 Mar 2024
The provider had information about complaints...but had not undertaken an investigation which identified any actions which could be implemented to reduce further risk.
moderatecare_planning22 Mar 2024
The care plan for 1 person whose support needs had increased did not reflect their new care needs...food intake was not recorded or monitored.
moderateperson_centred_care22 Mar 2024
Care plans were not accessible for people...the format was more designed for providing staff with information and not the person receiving the support.
criticalinfection_control22 Mar 2024
2 other staff members could not explain how they managed infection control...the provider did not have processes in place to ensure that infection control procedures were always followed.
criticalcare_planning22 Mar 2024
The provider had not developed personal emergency evacuation plans (PEEPS) for people who were being supported.
criticalcare_planning22 Mar 2024
Risk management plans...did not always identify guidance for all risks related to people's care or provide enough information for staff on how to mitigate the risks.