moderate“Some risk assessments lacked sufficient detail. For example, 1 person's environmental assessment of fire risks did not consider the barrier posed by a safety gate at the front door or the use of emollient creams.”
minor“Staff daily records did not consistently provide a full account of how people's needs were met, with some records consisting of a 'ticked' list of tasks.”
medication management
2 findings
moderate“We found some records contained insufficient guidance for staff in relation to the use of as and when required medicines. One person was prescribed a psychotropic medicine at a variable dose, due to anxiety.”
moderate“1 person's MAR audits in February, March and April 2023 had identified recording errors. The audits did not state what action was planned or taken.”
consent capacity
1 finding
moderate“Care records supplied for some people during the inspection did not adequately evidence why family members had signed key documents, including consent to receive care, on their behalf.”
care planning
1 finding
moderate“1 person's review in March 2023 identified a risk assessment was required in relation to their behaviour. This was not in place at the time of our visit.”
staff competency
1 finding
moderate“1 person's risk assessment for a health complication instructed staff to 'Check blood pressure every 5 minutes'... the person's regular staff member confirmed they had not received training to operate a blood pressure machine.”
governance
1 finding
minor“We found information was not accessible during our visit to explain gaps in staff employment histories. This information for 2 of 3 staff was provided following our visit.”
incident learning
1 finding
moderate“One person had experienced a recent fall. A staff member closed the incident record citing 'no further concerns', however no falls risk assessment had been documented.”
person centred care
1 finding
minor“We received variable feedback as to whether care needs assessments had explored if people would feel more comfortable supported by male or female staff.”