critical“The provider had failed to assess, monitor, and mitigate risks relating to the health, safety and welfare of service users. This is a breach of Regulation 17 (Good Governance)”
care planning
1 finding
moderate“One person's care plan did not contain sufficient guidance and direction for staff to manage all the risks related to their physical care and social support.”
safeguarding
1 finding
critical“One person's bank card and PIN were being used by staff to purchase shopping regularly. However, there were no checks, monitoring or audits of these transactions.”
record keeping
1 finding
moderate“In two care plans, it was recorded the individuals did not require to have decisions made on their behalf and in their best interests. Contrary to this, best interest decision meetings had been recorded.”
medication management
1 finding
moderate“On the day of the inspection, we found that some medicines did not match with the amount held. The registered manager did a complete audit and found some medicines incorrectly recorded.”
consent capacity
1 finding
moderate“One care plan stated the person did not have the capacity to make any decisions for themselves. Later it stated they could make decisions such as what food to eat, and clothing to wear.”
staff training
1 finding
minor“Recruitment processes were not always robust. One new staff file had not had a reference requested from their last care role.”