critical“The stock of the medicines was not always accurately recorded. Therefore, we could not be assured the correct amount of medicine was in stock.”
critical“Liquid medication was not always dated when opened. This meant people could be receiving medicines which had been opened past the recommended guidelines.”
moderate“Records to support staff to apply topical creams were not in place and there was no body map to identify where the cream should be applied.”
governance
2 findings
critical“Auditing tools were not always in place. Where audits were in place, they had not identified the concerns found during the inspection process.”
critical
“The provider had failed to operate effective systems to assess, monitor and improve the quality of the service. This was a breach of regulation 17.”
supervision appraisal
1 finding
moderate“Some staff told us they had not received a supervision in some time. Where staff had received a supervision, this was over the phone rather than face to face.”
incident learning
1 finding
moderate“Lessons learnt took place following on from an incident. However, the records were not always updated to reflect this.”
end of life care
1 finding
minor“Staff had not had training in this area. This meant if a person's health deteriorated, staff may not be trained to accommodate this.”
staffing levels
1 finding
minor“Staffing is like a roundabout, with sickness and moving staff around... This can cause stress to service users as they think one person is coming and it is another person.”