moderate“Staff had administered the cream from an existing supply, which was not dated with the date of opening. Staff should only administer a medicine which has either been prescribed or authorised.”
moderate“Two people had thickeners for their drinks which was stored in their unlocked bedrooms, this did not reflect national patient safety guidance.”
record keeping
1 finding
moderate“People did not have a falls risk assessment as per the providers policy and national guidance... their care plans did not mention their re-positioning needs.”
governance
1 finding
moderate
“Audits completed from January to March 2023 had not identified issues overall, however, the external assessment identified a range of issues.”
leadership
1 finding
moderate“There had been 3 managers of the service since January 2022. Governance processes had not been operated effectively prior to the new manager starting.”
staff training
1 finding
moderate“The provider had commissioned an independent assessment... the report had identified a number of aspects requiring improvement, including: incident reviews, recruitment, nutrition, staff supervision, training.”
supervision appraisal
1 finding
minor“The provider had commissioned an independent assessment... the report had identified a number of aspects requiring improvement, including: staff supervision.”
infection control
1 finding
minor“We were not assured that the provider's infection prevention and control policy was up to date.”