critical“There were no protocols to tell staff when they should administer 'when required' medicines, and staff did not record what medicines were contained in the blister packs they administered.”
safeguarding
1 finding
critical“The provider was unaware of the correct process for reporting safeguarding concerns to the local authority.”
governance
1 finding
critical“Effective systems were not operated to monitor, assess and improve the quality and safety of the service. This was a breach of Regulation 17(1) of the Health and Social Care Act 2008.”
leadership
1 finding
critical“There had been no registered manager in post for approximately three months...the provider did not demonstrate the experience and knowledge required to run the service safely.”
care planning
1 finding
moderate“In one case we found the provider had not given adequate consideration to the recommendations of a professional...staff were directed to carry out potentially unsafe practices in relation to moving and handling.”
consent capacity
1 finding
moderate“In some cases, it was not clear what decisions mental capacity assessments related to...the provider frequently referred to taking instruction from people's families without consideration of the individual's ability to take decisions.”
record keeping
1 finding
minor“In one case we saw the staff member had been employed before the provider had received written references...there was no record of verbal references.”