moderate“the service did not implement their policy and procedure to ensure a CDs register was in place. The registered manager said this was an oversight and took immediate action”
record keeping
1 finding
minor“recorded assessments did not always consider the storage of medicines to promote privacy and independence”
staff training
1 finding
moderate“National guidance recommends these types of techniques are usually for administrative staff or short term until more robust training is implemented”
staffing levels
1 finding
moderate“Staff recruitment processes such as employment references, reasons for leaving employment and recent photographic identification were not always robustly implemented”
safeguarding
1 finding
critical“The registered manager did not always recognise when to notify concerns of abuse to CQC as required, which meant one previous incident was not reported”
infection control
1 finding
minor“the service did not consistently advise visitors about hand hygiene or health screening to reduce the risk of catching and spreading infection”
governance
1 finding
moderate“Audits had not always identified shortfalls in implementing policies and procedures in relation to controlled drugs or staff recruitment”
incident learning
1 finding
minor“The management team told us they reviewed and acted upon every accident and incident although this was not documented on the report documentation”