critical“There were gaps identified on the MAR chart. The registered manager was unable to clarify why there were gaps.”
record keeping
1 finding
moderate“People's medicines records were not always collected in a timely manner from people's homes. This meant the management team were not able to review them.”
governance
1 finding
critical“Systems and processes to monitor, audit and improve the overall quality of the service were not robust enough.”
staff training
1 finding
moderate
“Evidence of a formal induction on staff files was incomplete, lacked detail and comprised of 1 day of training.”
staff competency
1 finding
critical“DBS certificates for 3 members of staff were received after they started work. There was no evidence to demonstrate the DBS update service had been accessed.”
care planning
1 finding
minor“People's care records were personalised but incomplete and contained limited information. No information was available about people's life history.”
end of life care
1 finding
minor“There was limited information in the support plans we reviewed relating to people's end of life wishes.”