critical“people with known health conditions such as; diabetes or Parkinson's disease did not have personalised care plans to ensure staff had clear guidance to follow”
medication management
1 finding
critical“protocols in place did not provide staff with clear guidance on the safe use of these [as required medicines]... not a safe and robust system when administering medicines.”
governance
1 finding
critical“governance system had not been operated effectively and had failed to identify the concerns we found during the inspection.”
consent capacity
1 finding
moderate“provider had not obtained evidence, that those making decisions on their behalf had the necessary legal authority to do so.”
record keeping
1 finding
moderate“for 1 person who required specific communication methods, their records did not reflect this support had taken place.”
infection control
1 finding
moderate“for a person who required continence aids there was not a detailed care plan in place to ensure aids were applied correctly and safely.”
incident learning
1 finding
minor“although they had identified some lessons learnt prior to the inspection, due to the lack of audits, this was not robust.”