moderate“A person's risk assessment was not in their care plan we looked at. The registered manager told us this risk assessment had been misfiled whilst transferring records to an electronic system.”
medication management
1 finding
moderate“Not all people's medicines administration records (MARs) were complete or accurate. Where people were supported with medicines that had to be administered before food, the time they had been administered had not been recorded.”
safeguarding
1 finding
critical“Incidents reported to the provider were not always sent to the local safeguarding teams for investigation.”
incident learning
1 finding
moderate“Staff provided us with the investigation record for an incident involving harm, but they were not able to find the records for what learning had been undertaken.”
governance
1 finding
critical“Not all quality audit and monitoring processes were effective in identifying, and enabling improvements. For example, not reporting incidents to the local authority where people had experienced harm.”
care planning
1 finding
moderate“Some risks to people had not been documented... information was not up to date on how to support people with drinking safely, such as the temperature of drinks and the drinking vessels to be used.”