moderate“Risks to people's health and safety were not consistently assessed. When risks to people were identified, it was not clear how the level of risk had been determined.”
moderate“One person had a catheter but there was no information about risks to the person in the event of complications, or signs and symptoms of complications.”
record keeping
1 finding
moderate“One person was at very high risk of falls, but records did not demonstrate how this level of risk had been reached.”
medication management
1 finding
minor“Some improvements were needed to ensure that staff were aware of medicines that needed to be administered with special instructions, such as being given 30 minutes before food or drink.”
consent capacity
1 finding
moderate“Records relating to people's mental capacity needed to improve. When care was provided in a person's best interests, there was no record of a mental capacity assessment.”
governance
1 finding
moderate“Systems had not identified the gaps we found in care plans and risk assessments.”