critical“The medicine record for this person did not name the individual medicines the person took. Their medicines were all in a blister pack and the medicine chart simply stated, 'blister pack'”
critical“They contained three instances where correction fluid had been used which meant it was not possible to see what the original entry had been.”
record keeping
2 findings
moderate“The registered manager told us they did not usually keep a record of these monitoring calls and was only able to produce three such records during the inspection.”
moderate“Two staff had left this section of their application form blank and there was no other record on the file to account for this.”
safeguarding
1 finding
critical“The registered manager was not aware of their responsibilities with regard to safeguarding...they would only report a safeguarding if the alleged victim agreed to this”
governance
1 finding
critical“Lack of effective quality assurance and monitoring systems and poor record keeping were a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.”
missed or late visits
1 finding
moderate“For one member of staff in that period they had six appointments and had only logged in and out for one of them.”
care planning
1 finding
minor“Not all care plans included [life history]. It was only included in one of the four care plans we reviewed.”