critical“Topical medicine administration records (TMARs) were not always in place for prescribed creams to ensure staff knew how, where and when to apply them.”
safeguarding
1 finding
critical“The provider did not always report safeguarding incidents to the local safeguarding authority and CQC. For example, incidents between people who used the service.”
incident learning
1 finding
critical“People were having multiple falls yet there was no evidence of learning or action taken to prevent repeat events.”
governance
1 finding
critical“The analysis for December 2020 showed a total of 5 incidents in the service yet our review found 23 incidents. This included multiple falls and incidents between people using the service.”
leadership
1 finding
critical“There was a lack of effective management and leadership. Staff described managers as friendly and approachable however, they said issues raised were not always acted upon.”
record keeping
1 finding
moderate“Care records for people using the service were not always accurate or up to date. Risk assessments and care plans were not always accurate or updated when needs changed.”
staffing levels
1 finding
moderate“The provider had no formal system in place to calculate safe staffing levels. Duty rotas showed these levels were not maintained.”
care planning
1 finding
moderate“One person had fallen frequently which resulted in serious injury on two occasions but their assessment showed they were at low risk of falls.”