moderate“the best interest decision had not been formally recorded. The registered manager told us they would put this in place.”
medication management
1 finding
moderate“gaps in medicine records for two people and a medicine error for another person had not been identified through the medicine audit.”
governance
1 finding
moderate“audits and checks carried out by the registered manager were not fully documented in relation to the management of the care provided.”
record keeping
1 finding
minor
“records of what care plans were checked and identified actions were not recorded by the registered manager.”
end of life care
1 finding
minor“We recommend that the provider supports people to express their preferences and choices for the end of their life.”
incident learning
1 finding
minor“there were two incidents that the registered manager had not been made aware of but action had been taken to ensure the person's needs were met.”
care planning
1 finding
minor“for one person, their communication needs had not been fully assessed to identify if staff could use other communication methods, such as pictures.”