critical“All of the MAR charts we looked at for the last three months contained gaps where there was no indication of whether the medicines had been administered, refused or omitted.”
medication management
1 finding
moderate“The absence of a robust quality assurance framework meant the provider had not identified and taken corrective action to address errors in the MAR charts.”
governance
1 finding
critical“The lack of effective quality monitoring of the service is a breach of Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2014.”
safeguarding
1 finding
critical“The registered manager and provider had failed to fulfil their legal responsibilities to notify the CQC of incidents where they suspected abuse may have taken place.”
staff competency
1 finding
critical“The provider had not always obtained all the information they are required to hold about staff before they were deployed to work at the service. This is a breach of Regulation 19.”
supervision appraisal
1 finding
moderate“They recorded supervision and spot checks in staff member's personnel files but they did not have an overview of this information.”
incident learning
1 finding
moderate“Whilst complaints had been addressed by the provider on an individual basis, they had not all been recorded within the complaints log.”