critical“one person who was cared for in bed, did not have a skin integrity risk assessment to assess the risk of the person developing pressure sores or a risk mitigation plan”
critical“there was not a risk mitigation plan or care plan to provide clear guidelines to staff. Information was spread across different records.”
safeguarding
1 finding
critical“We saw in the risk assessment that the person should only have pureed food, but one entry in the daily notes recorded the person had a sandwich.”
governance
1 finding
moderate“quality monitoring processes in place, but these were not always effective as they had not enabled the provider to identify and address the issues we found”
supervision appraisal
1 finding
moderate“The registered manager told us staff supervision was undertaken but we did not see written evidence of this.”
record keeping
1 finding
moderate“The provider did not always record their monitoring processes such as spot checks and supervisions which meant there was not always evidence of learning and service improvement.”
consent capacity
1 finding
minor“The provider did not get written consent from people, but agreed they would in future.”