critical“The provider had not operated an effective system to assess, monitor, and improve the quality and safety of the service provided. This is a breach of regulation 17.”
record keeping
1 finding
moderate“There was a lack of personalisation in care records...spelling errors in both care and audit records and an element of copying and pasting within daily note records.”
medication management
1 finding
moderate“The code recorded on a medicine administration record (MAR) relating to medicine doses not being available was not consistently recorded by staff.”
care planning
1 finding
moderate“Known risks for people had not been robustly risk assessed...one person had bed rails attached to their hospital bed, and this required a more in-depth risk assessment.”
staff training
1 finding
minor“There was a lack of oversight in relation to staff training. The initial training matrix received had not been updated to reflect training that had been completed.”
incident learning
1 finding
moderate“A falls risk assessment highlighted that a person had had two falls in one month...the registered manager had failed to record these two incidents.”
other
1 finding
moderate“New staff's full career history along with a written explanation of any gaps hadn't been explored by the registered manager.”