critical“Risk assessments were not always being reviewed and updated to reflect people's changing healthcare needs.”
medication management
1 finding
critical“the registered manager told us that they were currently crushing one person's medicines before administering via a PEG... we did not see appropriate guidance in place”
governance
1 finding
moderate“auditing systems were not always identifying the shortfalls we found in relation to risk assessment processes.”
staff training
1 finding
moderate
“staff had yet to complete training in stroke and epilepsy awareness despite already providing care to a person with both of these conditions.”
record keeping
1 finding
minor“employment references sent by email lacked company stamps/logos and the full professional title of referees.”