critical“Two references had not always been requested. A thorough interview process was not followed. DBS had not been requested prior to employment commencing.”
medication management
1 finding
moderate“Where people were prescribed 'as and when required' medicines, appropriate protocols were not in place to guide staff on when these should be administered.”
record keeping
1 finding
moderate“Records for topical medicines, such as creams, did not contain clear guidance of where these creams were to be applied.”
supervision appraisal
1 finding
moderate“One staff member commenced employment in November 2018 but had no recorded supervisions on their staff file.”
consent capacity
1 finding
moderate“Where people lacked capacity, decisions made in their best interests were not always recorded. Signed consent was not always in place.”
end of life care
1 finding
minor“Peoples preferences with regards to end of life care and support had not been considered or recorded.”
governance
1 finding
critical“Effective quality assurance systems were not in place to monitor the quality and safety of the service provided.”
leadership
1 finding
moderate“The registered manager did not have sufficient oversight of systems and processes to ensure regulatory requirements were met, such as safe staff recruitment.”