critical“Due to the lack of formal governance, lack of oversight with elements of medicines management, staff training and formal support for staff this placed people at risk of receiving poor quality of care.”
moderate“Audits were ineffective and not reviewed regularly. We found these to be mostly tick box audits, without action plans attached or with timescales for completion.”
record keeping
1 finding
moderate“gaps in staff recruitment files, such as not having a full employment history and staff were employed before relevant references were obtained. References received were not verified.”
medication management
1 finding
moderate
“We found protocols missing in some records for medicines prescribed as required (PRN). Protocols are important as they help staff understand when it is appropriate to offer PRN.”
supervision appraisal
1 finding
moderate“there were no formal supervision records kept on staff files and we there were only two completed spot checks.”
staff training
1 finding
minor“Staff had not started the Care Certificate. The registered manager told us they are in the process of starting The Care Certificate.”