critical“References were not always verified or appropriate, for example one reference was written by a relative of the applicant.”
staffing levels
1 finding
critical“Records of daily logs reviewed showed two staff did not always turn up to provide care. We could not be assured that people's needs were always met”
medication management
1 finding
critical“People were at risk of not receiving their medicines as prescribed. Medicine administration record charts and information about medicines were inconsistent and unclear”
care planning
1 finding
critical“Care plans were not always consistent... in one care plan it stated the person was fully dependent on assistance and bedbound, yet another plan for the same person stated the person did not require any help”
person centred care
1 finding
critical“care plans were not person-centred, and people's needs were not always met. This was a breach of regulation 9 (person- centred care)”
governance
1 finding
critical“Systems and processes for managing the service were not robust enough to ensure issues found during our inspection had been identified and addressed.”
incident learning
1 finding
moderate“evidence of learning from incidents and accidents were not recorded”
record keeping
1 finding
moderate“The service did not always maintain accurate care records relating to people using the service and staff recruitment records.”
other
1 finding
critical“risks related to pressure ulcers, choking or entrapment from bedrails were not considered. This put people at risk of harm”