critical“The provider did not complete risk assessments associated with people's medicines. The provider did not have assessment in place for the safe storage of medicines including any medicines which were temperature sensitive.”
critical“The provider did not have guidelines in place for staff to safely support people with 'when required' medicines including the maximum dosage within a 24-hour period to keep people safe.”
care planning
1 finding
critical“Staff members were not given current or accurate information on how to safely support people in their own homes as risk assessments had not been completed.”
staff competency
1 finding
moderate
“Although staff had received training in the safe use of medicines, they did not receive any spot checks or assessments of competency to ensure they followed safe processes.”
incident learning
1 finding
moderate“The provider did not effectively review all incidents, accidents or near misses to see what could be done differently to minimise the risk of reoccurrence.”
governance
1 finding
critical“The provider did not have effective quality monitoring systems. There was a lack of checks to ensure people received good care.”
leadership
1 finding
moderate“The provider did not have a manager registered with the CQC at the time of the inspection.”
supervision appraisal
1 finding
moderate“There was a lack of formal one-to-one with staff members or staff meetings. Staff believed they received information on an "ad-hoc" basis with no formal process.”
safeguarding
1 finding
moderate“The provider did not make information available to people, staff or relatives on how to report any concerns.”
person centred care
1 finding
minor“The provider had yet to formally introduce systems where they could gather and act on people's experiences of care and make improvements based on the responses.”