critical“we reviewed the call monitoring system and identified call visits were not taking place at the planned time.”
staffing levels
1 finding
critical“The provider had failed to ensure there was a system in place for the effective deployment of staff. This was a breach of Regulation 18 (1).”
governance
1 finding
moderate“The provider's systems did not always pick up some errors in people's care files and review notes.”
care planning
1 finding
minor
“there was a lack of guidance for staff to identify the signs of the person's health declining.”
record keeping
1 finding
moderate“1 person's review document had the wrong person's name recorded. Also, the mental capacity assessments for 2 people were not fully completed.”