moderate“There was no evidence that the management team investigated the incidents or accidents effectively or they analysed themes and trends in the accident and incident reports.”
medication management
1 finding
moderate“Medicine administration records (MAR) contained several unexplained omissions...no audits were completed for one person and only one audit had been completed for the other person.”
governance
1 finding
critical“Systems and processes to monitor quality and safety in the service were not established and operated effectively to ensure compliance with legal requirements. Regulation 17 (1)(2)(a)(c)”
safeguarding
1 finding
critical“The provider had failed to ensure CQC was consistently notified of reportable events without delay such as allegations of abuse. Breach of Regulation 18.”
care planning
1 finding
moderate“There was no evidence that the management team updated peoples care plans following a change in their needs. For example, following a fall where the person required medical support.”
missed or late visits
1 finding
minor“The registered manager was due to complete regular audits for monitoring late or missed visits...audits were only completed in February and March 2021.”