critical“we identified three examples where information of concern had not been appropriately escalated and reported to the relevant local authority where this was legally required.”
medication management
1 finding
critical“The provider failed to ensure medicines were safely managed where a person required their medicines to be administered covertly.”
governance
1 finding
critical“Quality assurance and governance systems in place were not always effective or robust...they did not identify the concerns we found at this inspection.”
record keeping
1 finding
moderate“multiple examples where the provider had failed to ensure people's care records were contemporaneous, accurate and consistently up to date to reflect their current needs.”
consent capacity
1 finding
moderate“assessments of people's capacity had not been undertaken or reviewed in line with requirements. This included decisions around peoples consent to their care and treatment and medicines support.”
incident learning
1 finding
moderate“the governance systems in place were not robust to ensure records were completed contemporaneously which meant an analysis of themes and trends could not be completed in a timely way.”
care planning
1 finding
moderate“several examples where information was conflicting or not always up to date across all relevant sections of peoples care plans.”
staff competency
1 finding
moderate“Staff had limited knowledge on their legal responsibilities to safeguard people...there was a lack of knowledge and understanding on when and how they could raise concerns.”