critical“Some people were routinely receiving doses of medicines too close together. This meant people were at risk of harm from a medicines overdose.”
moderate“Records for 'as and when required' medicines were lacking detail. This meant people were at risk of not receiving their 'when required' medicines appropriately.”
care planning
1 finding
critical“Two people required a hoist to move to and from bed. There was no risk assessment in place for this. This meant people were at risk of being moved incorrectly.”
governance
1 finding
critical
“The failure to have robust quality assurance processes in place is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”
incident learning
1 finding
moderate“It was not always clear what action was taken following an incident to help ensure similar issues did not occur again.”
record keeping
1 finding
minor“Some records did not include the dates of previous employment for staff. We could not be assured that references were obtained from the most recent employers.”
person centred care
1 finding
moderate“People's equality characteristics were included in some care plans but not all. There was limited person-centred information in care plans.”
communication with families
1 finding
minor“some were unhappy they were not told which carers would be visiting each week”