critical“The provider's quality assurance systems and processes were not effective. They had not enabled them to identify and address the concerns we identified at this inspection”
care planning
1 finding
moderate“where people were assessed to be at high risk of falls, staff had not always been provided with clear information and guidance, in people's support plans or risk assessments”
record keeping
1 finding
moderate“monitoring charts were not consistently completed, indicating people may not receive consistent support and monitoring. This meant people were at increased risk of developing skin damage.”
medication management
1 finding
moderate“People's medicines were not always stored safely. We observed that whilst a member of staff was administering medication, doses of 2 laxative medicines were left on top of the medicines trolley unattended.”
supervision appraisal
1 finding
moderate“There was no formal system of one-to-one staff supervision in place. The registered manager confirmed this. This meant there were missed opportunities to review staff performance”
person centred care
1 finding
minor“The premises had not been fully adapted to the needs of people living with dementia. For example, there was no directional signage to key areas and rooms to help people with dementia navigate”