critical“Systems and processes to assess, monitor and improve the quality and safety of the service were not always effective. This was a breach of regulation 17”
record keeping
1 finding
moderate“Records were not always sufficiently robust. This related to aspects of risk management, medicines records and to demonstrate full compliance with the MCA.”
medication management
1 finding
moderate“A new electronic system relating to medicines administration had been implemented. However, this needed amending to fully meet the needs of the service.”
consent capacity
1 finding
moderate“A decision to hide medicines away to keep a person safe had been made, however, records were not robust enough to demonstrate relevant assessments had been undertaken.”
leadership
1 finding
moderate“There was no registered manager at the service. Since the last registered manager had left, the director had managed the service.”
incident learning
1 finding
moderate“3 recent issues, identified during the inspection were submitted retrospectively, this had been an oversight by the provider.”
supervision appraisal
1 finding
minor“Systems relating to the oversight of the service had not yet been fully developed and implemented, for example in relation to the oversight of staff supervisions.”
staff training
1 finding
minor“Some staff had completed the Care Certificate and further work was being undertaken to ensure all staff had completed this.”