critical“Medicines were not safely monitored and managed. There was a lack of systems and processes in place to monitor and manage medicines”
critical“There was significant confusion around the difference between prompting and administration of medicines.”
care planning
1 finding
critical“People's known risks were documented in their care plans. However, known risks were not always risk assessed to provide guidance to staff on how to minimise the known risk.”
governance
1 finding
critical“There was a lack of audits to enable the service to assess and monitor the quality of care. The registered manager confirmed no medicines audits were completed”
record keeping
1 finding
moderate“pre-assessment documentation was poor. Documentation failed to document people's care and support needs, mobility, medicines and personal risks”
staff training
1 finding
moderate“training records which showed six out if 12 staff had not had safeguarding refresher training.”
complaints handling
1 finding
moderate“Complaints were documented. However, there was no information on any learning or how any complaints would be used to improve the quality of care.”
incident learning
1 finding
moderate“we also received feedback from the local authority that feedback to safeguarding teams was not always received in a timely manner.”
other
1 finding
minor“there were not always full employment histories and gaps in employment history had not been documented.”