critical“The systems used had failed to identify that four notifications had not been made to CQC.”
critical“The providers medicines policy had not considered how people's medicines records were accurate, up-to-date and in line with the person's prescription.”
incident learning
1 finding
moderate“Although complaints were logged and investigated there was no evidence of the provider taking any learning for improvements to minimise the chance of things going wrong again.”
communication with families
1 finding
minor“Three people told us that they were not really aware of who the managers were as there had been a number of changes. Four people told us communication could be improved.”
safeguarding
1 finding
critical“Relevant notifications had not been submitted to CQC where safeguarding reports had been referred to the local authority.”
medication management
1 finding
critical“staff told us they did not always have the person's prescription to accurately confirm that the medicines, dose and frequency were correct.”
care planning
1 finding
moderate“where a person had previously had a pressure sore and remained at risk of further pressure sores, there were no plans of care of how staff were to support them”
leadership
1 finding
critical“the provider was not meeting their legal requirement to have a registered manager in place.”
record keeping
1 finding
moderate“the written guidance on how to best support people in line with best practice was not always in place.”