moderate“some risks to people's care had not been recorded or the risk assessments were not detailed... moving and handling risk assessments had not been completed”
moderate“Improvements continued to be required in how risks to people's care were recorded.”
medication management
2 findings
moderate“one person's 'as and when required' medicine protocol lacked detail in relation to the time between dosages; this is important to ensure people do not overdose”
moderate“improvements continued to be required in the recording of 'as and when required' medication”
record keeping
2 findings
minor“Another person's body map lacked detail in relation to where to apply their prescribed cream.”
moderate“there wasn't a specific risk assessment for this risk”
governance
2 findings
moderate“quality assurance processes... had not always been effective in identifying some of the issues found at this inspection”
moderate“Medication audits were taking place regularly however these had not identified the issue found with the two PRN protocols.”
staff competency
1 finding
moderate“The service did not always follow safe recruitment practices. Evidence of pre employment checks before commencement of employment had not always been retained.”
safeguarding
1 finding
critical“we had to ask the registered manager to make a safeguarding referral due to one allegation made by a relative of unsafe moving and handling manoeuvre performed by staff”
incident learning
1 finding
moderate“There had been one safeguarding incident the registered manager had not reported to the Care Quality Commission in line with their responsibilities.”
supervision appraisal
1 finding
minor“spot checks were done regularly however, supervisions were not always completed for all staff members.”