critical“People's medicines were not always managed safely. Some Medicine Administration Records (MAR) were not correctly signed and did not have complete information.”
critical“Another person was short of medicines during the monthly cycle... The arrangements to monitor and reorder stock were not adhered to which placed the people at risk of not receiving their medicines.”
governance
1 finding
critical“These issues are a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
infection control
1 finding
moderate
“There were poor hygiene practices. There was a lack of oversight or inaction by the registered manager to ensure people received the support they required to minimise the risk.”
incident learning
1 finding
moderate“Learning from incidents and accidents was not always done in a timely manner. This meant missed opportunities for minimising a repeat.”
leadership
1 finding
moderate“The registered manager did not always provide adequate oversight to the care provided at the service. They relied heavily on managers and senior staff on site to oversee the operations.”
record keeping
1 finding
moderate“Record keeping was not consistently completed in the service and audit documentation required improvement.”
missed or late visits
1 finding
moderate“Some people did not always receive care in a timely manner... 'I have experienced delays'; 'The office telephone sometimes goes unanswered when I want to check the whereabouts of my carer'.”
communication with families
1 finding
minor“Relatives of people using the service and some staff were not always clear about the management structure and the roles of the different managers involved at the services.”