critical“People continued to receive medicines against the prescriber's instructions. For example, one person was prescribed a medication to take for six months. However, staff had continued to administer this medicine after the six months.”
care planning
1 finding
critical“Care plans did not accurately reflect instructions on how to give people medicines, meaning there was a lack of guidance for staff.”
safeguarding
1 finding
critical“Where people expressed concerns of potential abuse, they were not responded to in line with the provider's policy.”
governance
1 finding
critical“This was the fourth consecutive inspection where concerns were found in relation to record keeping and oversight of quality at the service.”
record keeping
1 finding
moderate“Records did not contain personalised information about people's needs, risks they were exposed to or their preferences about how they wished to receive their care.”
incident learning
1 finding
moderate“Systems and processes to review, investigate and monitor concerns, issues or incidents were not always completed correctly to demonstrate actions required or lessons learnt.”
leadership
1 finding
moderate“The registered manager did not always feel supported in their role. Following the inspection, the registered manager informed us they were leaving the service.”
staff competency
1 finding
moderate“Recruitment files were incomplete, which meant the provider could not demonstrate a robust and thorough recruitment process had been followed.”