moderate“risk reduction measures only stated, 'Not changed on time and does not like being too hot'. There were no guidelines for staff to recognise signs of skin deterioration”
minor“this did not always come across in their notes, as these lacked details about the social aspect of the visits. We fed this back to the registered manager”
care planning
1 finding
critical“some risk assessments did not include a risk management plan or guidance for staff to follow to help ensure they understood the person's condition and knew how to meet their needs”
incident learning
1 finding
moderate
“three incidents recorded in June 2019 and one in June 2018 did not contain details of investigations, actions taken, or lessons learned”
governance
1 finding
critical“monitoring systems had not always been effective and had failed to identify the issues we found in relation to risk management plans not being in place”