moderate“care plans did not always reflect people's preferences for how their care and support was provided, the routines they liked to follow or their wishes and aspirations.”
critical“one person was fed through their stomach but their risk assessment did not detail that they sometimes chose to eat solid food which would increase their risk of choking.”
governance
2 findings
critical“there were no records showing how the provider monitored records relating to people's care, such as care plans and risk assessments, to ensure they met the standards required.”
moderate“The registered manager did not have a clear plan in place that showed how they were monitoring all aspects of the service.”
record keeping
1 finding
critical“The provider had not ensured accurate and contemporaneous records were held about each person's needs in order to reduce risks to them. This is a breach of Regulation 17”
person centred care
1 finding
moderate“people's hopes, dreams and aspirations, and what steps staff needed to take to support people with these, were not always recorded.”