critical“The provider did not have suitable systems in place to ensure medicines were managed safely. People's medicines records did not contain enough information.”
governance
1 finding
critical“The provider's governance and quality assurance systems were not robust and were not fully embedded. This placed people at increased risk of harm.”
record keeping
1 finding
moderate“Systems needed to be established and embedded to formally monitor the quality and safety of daily records, medicine records, staff files and care files.”
supervision appraisal
1 finding
moderate“The provider had not ensured all staff received a planned, structured supervision in line with their own policy on staff supervision.”
staff competency
1 finding
moderate“The provider had stopped conducting spot checks and competency assessments of staff during the COVID-19 pandemic.”
consent capacity
1 finding
moderate“The provider did not have records to evidence how and when people's capacity to make their own decisions had been assessed.”
care planning
1 finding
moderate“Risks associated with individual medicines and creams were not documented, which meant people's care plans did not always contain enough information.”