critical“People were at increased risk of harm as medicines were not always managed safely.”
moderate“Where people had been administered 'as required' medicines, supporting evidence was not always available to show why they were given this medicine”
moderate“Medications received had not been checked and signed in to ensure correct medication and quantities were available.”
infection control
3 findings
critical“People were at risk of developing infections, as effective infection prevention and control systems were not in place.”
moderate
“Staff did not always wear appropriate PPE in accordance with the provider's policies and national good practice guidance to keep people safe.”
moderate“Cleaning schedules were not in place. The provider did not have any evidence to support additional infection control measures had been implemented”
governance
3 findings
critical“An effective system was not consistently operated to monitor the quality and safety of the service.”
moderate“medication audits did not identify the concerns we found on inspection in regards to recording, storing and returning medicines.”
moderate“There was an ineffective system for identifying and reporting environmental concerns. For example, some appliances and fixtures were broken”
record keeping
1 finding
moderate“monitoring documentation had not been completed in line with the provider's policies and procedures or identified areas we found on inspection.”
incident learning
1 finding
moderate“The provider did not gather and use information from the daily running of the service such as care plan reviews to learn and improve the care provided”