critical“Medicines which were given as needed did not have guidance and key information available to support staff administer these safely. Reasons for administering were not always recorded.”
critical“Medicines were sometimes given at the wrong time. Checks did not identify this which meant the provider could not take action to investigate and rectify.”
care planning
1 finding
critical“When people showed behaviour which indicated distress or agitation there was limited information about triggers, signs and what action staff should take to de-escalate.”
governance
1 finding
critical
“Quality assurance systems were not always effective at supporting staff to identify and take action about areas which needed improvement.”
safeguarding
1 finding
critical“Notifications to external agencies including the local authority and CQC about serious incidents or safeguarding concerns were not always made in a timely manner.”
record keeping
1 finding
moderate“Recruitment checks required strengthening to ensure the reasons for any gaps or anomalies were risk assessed. There were delays with 1 staff member receiving their criminal record check, but there was no risk assessment.”
supervision appraisal
1 finding
moderate“The system to support staff and their development was still being developed. These processes needed time to be embedded and sustained in practice for staff.”
incident learning
1 finding
minor“The provider planned to introduce monthly analyses of accidents, incidents, falls and behaviour indicating distress to assist with spotting trends and themes.”