critical“breach of Regulation 13...Safeguarding service users from abuse and improper treatment...registered manager had not ensured the systems and processes in place were operated effectively”
critical“two safeguarding concerns had not been reported to the local authority...Staff had recorded concerns in one person's incident record within their care plan in April 2016, but we found no evidence that this information had been reported”
medication management
2 findings
moderate“seven [safeguarding notifications] were regarding medicines errors, poor recording, and poor moving and handling techniques”
moderate“some medication errors at the service. For example, a staff member not signing the person's medication administration record to confirm the person had been given their medication”
record keeping
2 findings
moderate“seven were regarding medicines errors, poor recording, and poor moving and handling techniques”
moderate“staff did not record when they withdrew monies from a person's monies account...administrator told us they had not been given a copy of the policy as part of their induction”
staff training
1 finding
minor“there were two members of staff on the matrix who were overdue in completing one area of training”
governance
1 finding
moderate“the handover of information to the new manager was insufficient...checks the area manager told us they had completed, for example, care plan audits were not recorded”
leadership
1 finding
moderate“At the moment though, it's a proper mess. The manager has changed, and she doesn't understand how this works really”
care planning
1 finding
minor“People had risk assessments in place. We found that they could be more personalised and less generic.”