moderate“Risks to people were assessed and documented, but we identified two people being at risk of falls where this was not included in their care plans.”
safeguarding
1 finding
minor“Some staff members were unsure on aspects of whistleblowing procedures, but they understood the need to raise concerns about poor practice to keep people safe.”
record keeping
1 finding
minor“we found some unexplained gaps in staff's employment history in their recruitment files.”
medication management
1 finding
moderate“in the days prior to the inspection one person had not received their pain relief patch. The management team were not aware of this, as the month's medicines administration record audit had not yet been completed”
consent capacity
1 finding
minor“The provider had completed mental capacity assessments for people when needed but these could have included more information around the questions used and answers given.”
communication with families
1 finding
minor“Care plans included information on people's communication needs but could have included more specific information.”
end of life care
1 finding
minor“We found limited information in people's end of life care plan information.”
governance
1 finding
moderate“some of these systems could have been more robust such as the accidents and incidents audit.”
incident learning
1 finding
minor“There were a small number of accidents and incidents recorded with some evidence of learning lessons when things went wrong.”