moderate“1 person's choking risk assessment instructed staff how to position the person's head...but did not inform staff what changes to look for.”
critical“Known risks had not been assessed which put people at risk of receiving unsafe care. One person had epilepsy and another person was at risk of choking when they ate or drank.”
minor“one person's assessment told staff the equipment to use was a 'banana board' but there were no instructions about how to use this”
medication management
2 findings
moderate“recording omissions we found on 1 person's medicine record had not been identified by the management team.”
critical
“Records had not been completed to show when and which prescribed medicines had been taken or declined...the provider could not demonstrate people were receiving their medicines safely.”
governance
2 findings
moderate“further time was needed for audits and checks to be fully effective and embedded...audits of medicine administration records had not identified the omissions we found.”
critical“Medicines audits had not been completed and audits of people's care records had not identified the concerns we found. This put people at risk of receiving unsafe care.”
record keeping
1 finding
critical“Accurate and complete records in respect of each person were not maintained...staff did not always have the information they needed to provide safe, personalised care.”
staff competency
1 finding
moderate“A gap in 1 staff member's employment history had not been explored and a second staff member's file did not contain a reference from their last employer.”
communication with families
1 finding
minor“Some relatives had not been invited to provide feedback about the service and told us they felt communication with the management team needed to be improved.”
consent capacity
1 finding
minor“where relatives had formal agreements to make decisions on people's behalf a copy of the authorisation was not available”