critical“There was an audit tool in place but regular quality checks had not been completed. This included reviews of people's care plans and audits of medication charts.”
medication management
1 finding
moderate“One person was prescribed medicine to be taken four times a day. Staff did not record the times of administration which meant we could not be assured there was a four-hour gap between doses.”
care planning
1 finding
moderate“Some people's risk assessments did not contain a lot of detail and had not been recently reviewed. One person had experienced a recent significant fall but their risk assessments had not been updated.”
incident learning
1 finding
minor“The provider had a system for monitoring and reporting accidents. This could be improved to ensure near miss events were also captured and used to learn lessons.”
record keeping
1 finding
minor“The registered manager and staff told us about examples where they had contacted and worked closely with health professionals. This was not always clearly reflected in people's care notes.”