critical“Medicine administration records (MAR) did not state the full medication name or dosage and had not been signed at the beginning of the medication cycle to confirm stock levels received.”
critical“MARs had not been audited by the provider for over 6 months. This meant the provider did not have oversight of people's medication”
governance
2 findings
critical“Poor oversight meant risks to people's care and support were not always sufficiently monitored and placed people at the potential risk of harm”
critical“The systems in place were not embedded into the service, with many audits either not being completed or documented fully. People's daily records were not being checked.”
record keeping
1 finding
moderate“Multiple gaps in recording on MARs were observed... correct codes were not being used to explain why medications had not been administered.”
leadership
1 finding
moderate“The registered manager did not have consistent oversight of the service.”
safeguarding
1 finding
moderate“Safeguarding incidents had been reported to the local safeguarding team; however, these had not always been sent to the CQC in a timely way as required.”
incident learning
1 finding
moderate“consistent analysis wasn't being undertaken to learn from these when things had gone wrong.”
care planning
1 finding
minor“Some care plans had not been reviewed or audited since they were implemented”
staffing levels
1 finding
minor“we are struggling to get staff and due to some of our clients living in rural areas it makes it difficult to recruit.”