critical“the dosage and frequency between doses was not recorded which meant the person could be given more medicines than was safe.”
governance
1 finding
critical“continued breach of Regulation 17 (Good governance)...medicines records were not robust and good recruitment processes were not being followed.”
record keeping
1 finding
critical“Records were not completed accurately or well maintained. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008.”
staff training
1 finding
moderate“the registered manager employed staff, they were not following their own internal policies by ensuring staff undertook mandatory training before commencing in the role.”
leadership
1 finding
moderate“The service lacked vision and appropriate planning for how good outcomes for people would be achieved.”
staffing levels
1 finding
moderate“A staff member had been employed without appropriate DBS checks being applied for.”
care planning
1 finding
minor“There was a short history about 1 person in their care plan, but little other detail...the registered manager was unable to tell us the details of both of those agencies.”