critical“the person's risk management plan made no reference to the one scoop of thickener directed by a healthcare professional.”
minor“these needed to capture the target goal the person needed to reach to maintain a healthy balanced diet and the daily amount of fluids needed to be totalled.”
person centred care
2 findings
minor“care plans were in a written format, which meant personal information was not always accessible to people...the provider had not given consideration to including pictorial formats.”
minor“There was no information readily available about advocacy for people however, the deputy manager agreed to ensure information would be included within the information pack.”
care planning
1 finding
moderate“one person's 'bed' was recorded as a 'severe hazard'. However, the risk should have been recorded as the person climbing over their bed rails.”
governance
1 finding
critical“This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”
incident learning
1 finding
moderate“we found no evidence of lessons learned because we identified similar areas in need of improvement at their Nuneaton branch as to those previously identified”
staff training
1 finding
moderate“one staff's DBS had been requested by the provider two years before the staff member commenced work. There was a risk the provider did not have up to date information”
medication management
1 finding
moderate“one person had their medicines administered through their PEG...MAR directed staff to crush tablets. However, we found no recorded discussion about this from this person's GP”
consent capacity
1 finding
moderate“Improvement was needed in recording best interest decisions in peoples' care plans. This included who could make best interests' decisions on behalf of people, such as those under the age of 16.”