moderate“People receiving topical creams did not have accurate records in place. The provider had not taken into account that topical medicines, such as creams, are a medicine should be clearly documented.”
safeguarding
1 finding
critical“We found not all incidents had been appropriately investigated and escalated to the local safeguarding authority. We reported this incident to the local safeguarding authority during the inspection.”
consent capacity
1 finding
critical“The registered manager had not understood the need to assess if these people had capacity to consent. This was a breach of Regulation 11 of The Health and Social Care Act 2008.”
care planning
1 finding
moderate“One person required a special diet, there was no detailed plan of how staff should provide this. One person was receiving end of life care, there was no plan in place which detailed their wishes.”
governance
1 finding
critical“The systems in place to check the quality of the service were not consistently effective. This was a breach of regulation 17, of the Health and Social Care Act 2008 good governance.”
record keeping
1 finding
moderate“Staff understood people's risks and how to minimise them, there was not always clear documentation in place to guide staff. No assessment of the risk of choking, no detailed description of the actions staff took.”
end of life care
1 finding
moderate“People that were receiving end of life care had no plan in place to share their wishes with staff. This meant we could not be assured the person's needs were being met in the most appropriate way.”