critical“a topical medicine was out of date and had continued to be used by care staff. The auditing systems over a 3-month period had not identified this.”
governance
1 finding
critical“provider had failed to make sure there were effective and robust systems in place to monitor risk and oversee the safe performance of the service. This was a breach of regulation 17”
safeguarding
1 finding
critical“some statutory notifications that should have been submitted to us had not always been sent.”
record keeping
1 finding
moderate“processes used for checking the quality of care plans did not identify that for 4 people risks associated with the use of some equipment such as bed rails and wheelchairs had not been completed.”
care planning
1 finding
moderate“care records did not provide a detailed plan for managing the risks associated with some of the equipment people required such as bed rails and wheelchairs.”