critical“comprehensive risk management and escalation plans had not always been completed for all people who required specific support requirements such as catheter care and moving and handling”
medication management
1 finding
critical“staff would benefit from further guidance around the management and preferred administration of people's medicines and application of barrier creams”
record keeping
1 finding
critical“Comprehensive risk and medicine management plans had not been put into place to guide staff which placed people at risk of harm. This was a breach of regulation 12”
staff competency
1 finding
critical“complete references and background checks had not always been obtained to evidence the good character of staff”
governance
1 finding
moderate“further time was needed to assess if the new systems and senior team would be effective in monitoring the quality of the service and identifying gaps in people's care records”
consent capacity
1 finding
minor“the provider's system to assess people's mental capacity on their current care data management system...was not comprehensive in demonstrating how people's mental capacity would be assessed”