moderate“Risks to people had been assessed. However, these did not identify individual risks or mitigating actions for staff to follow to keep people safe.”
moderate“People's care plans did not contain information relating to specific health conditions and how this impacted on the person. In addition, we saw care plans which contained the names of other people.”
governance
1 finding
critical“The quality assurance system was not effectively used to identify shortfalls of the service and did not support driving change or development of the company.”
incident learning
1 finding
critical
“We found incidents of missed medication and falls which had occurred but had not been reported.”
record keeping
1 finding
minor“A lone working risk assessment had been completed by the registered manager. However, this had not been scored correctly and lacked information to mitigate risks to staff.”