critical“Risks to people had not always been identified. Clear guidance was also not always in place to manage risks that had been identified”
critical“there was no environmental risk assessment for one person's home and one person was at risk of taking too much medication after drinking alcohol but no measures to manage this risk”
incident learning
2 findings
moderate“under the previous manager, actions had not always been taken following an incident to reduce the risk of the same thing reoccurring”
critical“one person had fallen asleep whilst smoking but no risk assessment was in place to identify measures to reduce the risk of a fire.”
governance
1 finding
critical“further work was needed to ensure robust quality assurance systems were fully implemented by the manager and the provider had sufficient oversight of the service”
leadership
1 finding
moderate“there had been a further change of ownership, management arrangements and the nominated individual had left. This showed the leadership at the service continued to be inconsistent.”
record keeping
1 finding
minor“the recording of financial transactions could be improved further”
safeguarding
1 finding
moderate“We were aware of a safeguarding that was currently being investigated relating to charges for the support provided by Manchester Prime Care under the previous registered manager.”