critical“one person was at risk of absence seizures, however there was not an appropriate risk assessment in place. Another person had a history of strokes, but there was no risk assessment in place”
moderate“we looked at a sample of care plans and noted that they had not been reviewed since 2020”
record keeping
1 finding
moderate“the level of detail in each person's care records varied and information was not consistently recorded”
governance
1 finding
critical“The current auditing systems in place were not robust enough to assess and improve the quality and safety of the services being provided to people.”
leadership
1 finding
moderate“At the time of the inspection there was not a registered manager in post.”
supervision appraisal
1 finding
minor“the information documented in these were generic and there was a lack of detail as to what was discussed during these sessions”
staff competency
1 finding
moderate“a number of staff had not completed medicines competency checks”
staff training
1 finding
minor“The training matrix indicated that the majority of staff had not completed end of life training.”
other
1 finding
minor“there were instances where it was not clear who had provided these as referee details were limited. There was a lack of evidence to confirm that references had been verified”
end of life care
1 finding
minor“Care plans did not evidence a discussion surrounding end of life wishes had been considered.”
communication with families
1 finding
minor“It is difficult to contact them in an emergency, bad communication.”