moderate“one person had experienced a fall, but their risk assessment indicated no falls”
minor“there was a gap in one staff member's employment and the other staff's full employment history was not available”
minor“Care staff did not always adhere to one person's specialist diet and did not always calculate the total amount of fluids people had drunk during the day.”
infection control
2 findings
moderate“not all staff were wearing face masks appropriately and robust arrangements had not been made to separate people from a person who was self-isolating following a positive test for coronavirus”
moderate
“One person and two members of staff told us slings used with the hoists were shared. This meant people were at increased risk of cross infection.”
consent capacity
2 findings
minor“there was limited information in people's care files about why the DoLS application had been made and how people should be supported in the least restrictive way”
critical“Staff had completed and signed best interest decision making forms for people to live in the home irrespective of their ability to consent to their care.”
incident learning
1 finding
moderate“Accidents and incidents had been recorded and entered onto electronic databases; however, an analysis had not been undertaken to identify any patterns or trends.”
staffing levels
1 finding
moderate“At night, there are not enough staff. A long wait is usual. I've also had to wait in the day when the staff have been dealing with everyone else.”
medication management
1 finding
moderate“Staff had not always applied prescribed creams in line with the prescriber's instructions. We also saw there were two crushed tablets on one person's bedroom floor.”
governance
1 finding
moderate“The quality assurance systems were not always effective in identifying shortfalls.”
person centred care
1 finding
minor“On Cedar Grove both the television and music on at the same time. This made the atmosphere confusing and oppressive. We also noted staff had little communication with people and were task focussed.”
communication with families
1 finding
minor“People spoken with felt they were not fully informed about any actions from the meetings.”