critical“There were no MAR sheets or body maps in place for topical creams that staff were applying.”
critical“One person had not been supported to take their medicines at the correct time. This meant they were put at risk of avoidable harm.”
safeguarding
1 finding
critical“one incident had involved the police but the provider had not reported this to the CQC or the local council.”
staff training
1 finding
critical“The provider could not evidence all training had been completed, this meant people were at risk of being supported by staff who were not appropriately trained.”
staff competency
1 finding
critical“The provider had failed to complete competency checks to ensure staff were managing medicines safely.”
staffing levels
1 finding
moderate“the manager and the administration officer were working with people on a regular basis and were struggling to safely oversee the service.”
governance
1 finding
critical“There were ineffective audits in place so issues could not be identified and acted on effectively.”
incident learning
1 finding
moderate“The provider had not introduced systems to look at what went wrong and why.”
care planning
1 finding
moderate“one person experienced pressure sores but there was no management plan for them. Another person did not have detailed guidance on how to support them when there got anxious.”
record keeping
1 finding
moderate“Incidents and accidents were reported but the quality of reporting was poor with missing information about when incidents occurred and to whom.”