moderate“Some risks to people were not identified and assessed and care plans did not have all the information staff needed to manage risks safely.”
critical“A person was receiving their nutrition and medicines through a RIG tube. There was no risk assessment or care plan in place to guide staff.”
moderate“Risks associated with the use of oxygen had not been considered as part of the provider's environmental risk assessment process.”
governance
1 finding
moderate“Systems for identifying and managing risks were not fully embedded...quality assurance systems had not identified these shortfalls.”
record keeping
1 finding
minor“When a best interest decision was made, the provider had involved relevant people and professionals but had not fully recorded the best interest decision.”
person centred care
1 finding
minor“Some care plans lacked personalised detail. For example, people's wishes for end of life care were not well recorded.”