critical“One person had health conditions which impacted on their ability to eat...There was no nutritional risk assessment completed to show how staff should reduce this known risk.”
moderate“Another person had a recent change to their moving and handling requirements. However, their care plan had not been updated to reflect the new requirements.”
governance
2 findings
critical“Governance systems were not effective...resulted in a lack of oversight for accident and incidents, medications, care plans and risk assessments.”
critical“The registered manager failed to notify the Care Quality Commission of two accidents which were reportable under the statutory notification requirement.”
medication management
1 finding
critical“Staff were not always recording whether they had checked if people had eaten prior to receiving these medicines. Guidance was not in place for 'as required' medicines.”
incident learning
1 finding
moderate“Incidents and accidents were recorded, but were not consistently reviewed or analysed for patterns or trends.”
missed or late visits
1 finding
minor“One relative said, 'Very often they are late, we asked for a specific time, but they don't come at that time.'”
complaints handling
1 finding
minor“We found one example of a complaint received where staff had not been informed of the new protocols agreed.”