moderate“Protocols were not in place for people requiring 'as and when needed' medicines such as, pain relief. This left the person at risk of either receiving too much or not enough of their prescribed medicines.”
moderate“Medication Administration Records (MAR) had not been completed consistently. Missing signatures were found on people's MAR which could not provide assurance.”
governance
1 finding
critical“The provider had failed to have effective governance systems in place to asses, monitor and improve the quality of the service that was provided to people.”
care planning
1 finding
moderate
“Care plans contained an inconsistent level of detail and personalisation. Some records were very detailed and outlined how the person wanted their needs met and other records lacked detail.”
record keeping
1 finding
moderate“Some people had comprehensive risk assessments and guidelines... Whereas other people's care records contained no information about risks posed to them and others.”
safeguarding
1 finding
critical“The registered manager had raised a potential safeguarding concern with the local authority. However, a statutory notification had not been sent to the Care Quality Commission (CQC).”
staff training
1 finding
minor“Full employment histories including an explanation of any gaps in employment had not been documented.”
end of life care
1 finding
minor“Care records lacked detailed outlining the care and support the person wanted to receive at the end of their life.”
incident learning
1 finding
critical“Statutory notifications had not been submitted to CQC for an allegation of abuse and when there had been an expected death.”