moderate“School, college and university attendance dates were not recorded so it was unclear if there were any gaps in the staff members employment history after leaving education and starting work.”
governance
1 finding
critical“Quality monitoring systems were not robust enough to accurately monitor and identify areas found requiring improvement. This was a breach of Regulation 17(1).”
staff training
1 finding
moderate“Spot checks had not been completed in areas such as catheter care. Records did not always contain evidence of all staff training they said they had completed, such as catheter care training.”
medication management
1 finding
moderate“'As required' medicine information for medicines such as pain relief, lacked enough detail to guide staff. The information did not inform staff of the maximum dose within 24 hours.”
care planning
1 finding
moderate“In one person's care record we found the persons gender changed part way through, and there was an incorrect health condition listed. There was also conflicting information as to whether they wished to be resuscitated.”
safeguarding
1 finding
critical“The governance monitoring system had failed to identify that a safeguarding allegation had not been notified to the CQC using the correct notification form. This is a legal obligation.”
staff competency
1 finding
critical“Potential new staff recruitment checks needed to be more robust to help ensure safe staff recruitment. This was a breach of Regulation 19 of the Health and Social Care Act 2008.”