critical“The provider failed to have in place fully accurate, complete and contemporaneous records in respect of each service user. Breach of regulation 17.”
medication management
1 finding
critical“Systems and procedures were not in place to ensure that people's medicines were accurately recorded. Staff did not always appropriately record why a medicine was not administered.”
governance
1 finding
critical“Systems were not in place to effectively assess, monitor and improve the quality and safety of the service. Breach of regulation 17.”
staff competency
1 finding
critical“The provider failed to have safe recruitment procedures in place. The provider did not consistently obtain full employment histories or appropriate references.”
care planning
1 finding
moderate“People's care plans were not always up to date. Some care plans contained out of date information and guidance for staff.”
incident learning
1 finding
moderate“Incidents had occurred which were not included in the provider's monthly incident reports. This meant that oversight was not effective, and trends could not be identified.”
missed or late visits
1 finding
moderate“Systems were not in place to analyse key performance indicators such as late or missed calls.”