21 September 2017
During an inspection looking at part of the service
This inspection was unannounced and the registered manager was not available on the day of the inspection as they were on annual leave. We subsequently asked them to provide information to us. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager of this service was also registered as manager of another of the provider’s services.
We had been advised that there had been medicine errors which had resulted in an individual being admitted to hospital and staff suspended from administering medicines to people. The errors had the potential to result in serious harm to people’s wellbeing.
We found that the systems that were in place to manage medicines were not working effectively. The agency were not always following their own policy and procedures. Risks were not being identified and managed.
Audits were undertaken but were not robust and did not drive improvement.
You can see what action we told the provider to take at the back of the full version of the report.