moderate“Spot checks and medicines competencies completed to ensure staff were safe to provide care to people had not been documented.”
minor“The regulated activities and service user bands for the service were not up to date and did not accurately reflect the services provided.”
supervision appraisal
2 findings
minor“Not all staff had completed an appraisal within the last year however supervisions had taken place.”
minor“One relative told us that they had never experienced the support staff being observed by more senior staff. This was fed back to the provider who undertook to check the observation charts.”
governance
1 finding
critical“The provider had not operated an effective system to assess, monitor and improve the quality and safety of the service provided.”
incident learning
1 finding
moderate“There was no evidence the service analysed themes and trends in the accident and incident reports and ensured measures were in place to reduce the likelihood of repeat events.”
medication management
1 finding
minor“One MAR did not include information such as specific instructions for giving a medicine, any known drug allergies and the name of the person's GP practice.”