critical“When people's needs had changed, care plans and risk assessments were not updated in a timely manner.”
medication management
1 finding
moderate“staff were not always recording where people's patches were applied, and one person's prescribed cream had been applied but was not on the medication administration record.”
governance
1 finding
critical“Governance systems were not effective to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.”
record keeping
1 finding
critical“The provider had not maintained accurate, up to date records. Care plans were not always reflective of people's needs and they had not always been updated promptly.”
staff competency
1 finding
moderate“gaps in employment had not always been explored.”