critical“Where specific health conditions meant people may be at risk of ill health guidance was not always in place to inform staff of the signs they should look for, action to take”
medication management
1 finding
critical“Staff supported a number of people by preparing their medicines and leaving them out for them to take later... We found no risk assessments or guidance for staff had been completed.”
consent capacity
1 finding
critical“The provider was unable to demonstrate their understanding of the MCA processes... only one staff member had completed MCA training.”
governance
1 finding
critical“There was no system in place for ensuring that care records were regularly checked and updated... structured audit systems were not in place.”
record keeping
1 finding
moderate“Other people's care records contained contradictory information which meant people may be at risk of not receiving the right care.”
safeguarding
1 finding
critical“External doors were locked preventing the person leaving and the persons telephone was removed at night... no capacity assessment or best interest decision had been completed.”
end of life care
1 finding
minor“One area that could improve was the level of detail to guide staff on meeting religious or cultural needs...the information on what staff could and could not do regarding the persons faith was limited.”