critical“staff had signed that a cream had been applied to a person on 3 different days, but the staff had previously recorded in the daily notes, the cream had not been available.”
critical“A person was prescribed with medicine to be administered 3 times a day but the MAR indicated the person had not taken the medicine this month. This had not been reviewed or followed up with a GP.”
governance
1 finding
critical“Systems and processes to monitor, audit and improve the overall quality of the service were not robust enough. This was a breach of Regulation 17 [Good governance]”
incident learning
1 finding
critical
“there had been occasions whereby statutory notifications had not been sent to CQC as required. The failure to notify CQC of notifiable incidents is a breach of regulation 18”
end of life care
1 finding
minor“There was limited information in the support plans we reviewed relating to people's end of life wishes.”
record keeping
1 finding
moderate“We were not assured the current governance arrangements and oversight of the service were robust...with regard to; medicines management, audits, completion of documentation including people's daily notes”