critical“people were at risk of not receiving their regular and as required medicines and medicinal creams as prescribed as clear medicine management plans and protocols were not in place”
critical“Medicines risk assessments were not in place which may put some people at risk of avoidable harm; for example, there was no clear risk assessment in place for people who are at increased risk when taking anticoagulants”
care planning
1 finding
critical“Where these protocols identified risk to people, these risks had not always been assessed and appropriate risk management plans were not in place for people who may experience falls, epilepsy, swallowing difficulties”
governance
1 finding
critical
“effective systems had not been established to assess and monitor the service being provided. Complete and contemporaneous records were not always in place”
record keeping
1 finding
moderate“The documentation of medicines and the auditing of these records to ensure the safe management of people's medicines required improvement.”
consent capacity
1 finding
moderate“People's consent to the management of their risks and supports needs had not always been obtained by the provider in line with the principles of the Mental Capacity Act (2005).”
staff competency
1 finding
moderate“Records relating to the pre-employments checks that had been completed required some more detail to support the registered managers decision to employ them.”
communication with families
1 finding
minor“Some people felt communication could improve if staff were running late.”
other
1 finding
moderate“Staff may be at risk as they did not always have access to information about any risks of lone working and any associated environmental risks”