Note29 Sept 2022
Staff morale was positive, with staff expressing genuine commitment to person-centred care.
Note29 Sept 2022
Registered manager engaged with external organisations and peer forums to share good practice.
Note29 Sept 2022
Good communication between management, care staff, and family members.
Note29 Sept 2022
Safe recruitment practices including DBS checks and structured induction.
Note29 Sept 2022
Sufficient staffing levels with consistent staff allocation, promoting continuity of care.
Note29 Sept 2022
Risk assessments were in place with clear guidance for staff, including catheter care and moving and handling.
Note29 Sept 2022
Staff demonstrated cultural competency, including learning to prepare culturally appropriate meals such as Jamaican food.
Note29 Sept 2022
Family members spoke positively about staff being kind, caring, and having a positive impact on relatives' day-to-day lives.
moderaterecord_keeping29 Sept 2022
The topic such as 'notes audit' and 'medication records' was followed by a tick or yes, with no information as to what evidence had been used to assess quality.
minorsafeguarding29 Sept 2022
Not all staff were aware of external organisations they could refer safeguarding concerns to. For example, the local authority safeguarding team.
moderateconsent_capacity29 Sept 2022
The best interest decision was not supported by a clear and agreed protocol of care for staff to follow.
moderatestaff_competency29 Sept 2022
We could not be confident in the competency assessments of staff given they were not consistently following the provider's policy or procedure for medicines.
moderategovernance29 Sept 2022
Audits did not record what action was to be taken, by whom and when and subsequent audits showed improvements were not consistently achieved.
criticalgovernance29 Sept 2022
Audits had failed to identify medication administration records, and medication administration, were not being carried out in line with the provider's policy.
criticalmedication_management29 Sept 2022
A person's care records instructed staff to administer medicine from a dosset box prepared by a family member and not by a pharmacist.
criticalmedication_management29 Sept 2022
People's medicine administration records did not always record the dosage or the name of the medicine prescribed.