moderate“Medicine administration records (MAR) did not record details of why PRN medicines had been administered. Staff were required to record this in the person's daily records.”
moderate“Medicine care plans did not consistently record where people's medicines were stored, what the medicines were for, and what people's preference was of how they should be administered.”
governance
1 finding
critical“Systems and processes were not fully effective to assess, monitor, mitigate risks and improve the quality of the service. This was a breach of regulation 17(1) Good governance.”
record keeping
1 finding
moderate
“We found gaps in care records because information was stored in different places. Whilst no person had come to harm it is important the provider maintains accurate and clear running records.”
incident learning
1 finding
critical“Not all safeguarding incidents had been reported to CQC as required and this increased the risk of reoccurrence.”
staff training
1 finding
moderate“Staff had not all completed mandatory training in learning disability and autism awareness that we expect all staff of registered services to complete.”
supervision appraisal
1 finding
minor“The registered manager had recently increased the frequency of staff supervision meetings from 6 to 3 monthly as requested by the local authority.”
care planning
1 finding
moderate“Changes to people's care and support needs and actions taken in response, were not consistently recorded.”
consent capacity
1 finding
minor“Best interest decisions had been made in consultation with others, this needed to be clearly recorded of who, when and how this had been completed.”
safeguarding
1 finding
moderate“Staff had not completed incident documents as required. Failure to record information impacted monitoring procedures being safe and effective.”