critical“Some people's risks had been fully assessed where others did not contain any assessed information relating to potential risks to people, such as risk of falls.”
medication management
1 finding
critical“Records of medicines people were required to take and information available to staff was inconsistent... other people who did not have this in their care plan.”
staff competency
1 finding
moderate“Staff had not been routinely assessed on their ability to safely administer medicines. This meant the provider could not be assured staff were competent.”
governance
1 finding
critical“Audits and checks of the service had not taken place regularly in the months prior to the inspection... no evidence of trends analysis to further aid learning.”
record keeping
1 finding
moderate“The provider failed to maintain accurate and complete care plans, risk assessments and daily records and these were not consistently detailed.”
leadership
1 finding
moderate“At the time of our inspection there was not a registered manager in post. The previous registered manager left the service in May 2022.”
incident learning
1 finding
minor“Staff knew how to report concerns... but told us they don't always receive feedback on what had happened since or as a result of these being raised.”