critical“medicines records had not always been completed in line with best practice...hand transcribed medicines had not always been signed and checked and body maps were not in place”
critical“one person's medicines as they were running out of stock, meaning they were not receiving these and the providers audits had not identified this.”
governance
1 finding
critical“Governance systems in place were not effective. Although audits took place, they had not always identified areas found at this inspection.”
care planning
1 finding
moderate
“Care plan audits had failed to identify when sufficient person-centred information was not in place and risk assessments were not sufficiently robust or in place.”
record keeping
1 finding
moderate“Accurate and contemporaneous records were not always kept. For example, accident reports management review section and action taken was not completed.”
incident learning
1 finding
moderate“Accident and incidents records were in place but had not always been sufficiently completed in terms of action taken to reduce the identified risk and the management review.”
staff training
1 finding
moderate“Some staff had not been enrolled on their Care Certificate...There was a lack of oversight of training. They had not identified when staff had not been enrolled on their Care Certificate.”
supervision appraisal
1 finding
minor“I have not had a supervision yet but had regular observations and spot checks.”
complaints handling
1 finding
minor“When informal concerns had been raised, these had been addressed promptly. However, they had not always been recorded as a concern.”