minor“there was no defined schedule of provider level audits. We discussed this with the provider and registered manager who told us provider audits would be scheduled to take place on a quarterly basis in future.”
critical“A 'registered manager's monthly monitoring form'...had last been recorded as completed in March 2017...There was no record of any quality assurance checks or systems carried out by the provider.”
record keeping
2 findings
minor“The registered manager did not document non-formal complaints and their outcomes at the time of inspection.”
moderate“Training records were not always up-to-date or reflective of training completed...The registered manager said they were sure training had taken place and that the training chart was not accurate.”
medication management
1 finding
minor“A medicines policy was in place which required updating. The registered manager told us this work would be undertaken.”
staff training
1 finding
critical“Some training expired in 2017. The chart also showed that some staff had never completed mandatory training in some areas such as fire safety and infection control despite having worked at the service for a number of years.”