critical“Most relatives we spoke with told us their relative frequently received late calls and on occasion had experienced missed calls.”
medication management
1 finding
moderate“Medication care plans did not always contain detailed information about the medication or specific guidance about how the medication should be administered.”
record keeping
1 finding
moderate“three people's medication care plans and medication administration records (MAR) contained conflicting information”
care planning
1 finding
moderate“Care plans did not always contain enough information about people's needs and preferences.”
governance
1 finding
critical“The provider's quality assurance systems and processes were not sufficiently robust to address the shortfalls we found during the inspection.”
safeguarding
1 finding
critical“The registered manager did not always notify us about potential safeguarding incidents.”
incident learning
1 finding
moderate“Trends in incidents and accidents had not been explored in detail. This meant opportunities to prevent reoccurrence an improve safety were missed.”
other
1 finding
moderate“application forms contained missing information, interview records were not always completed, school leaving dates were not always included, and gaps in employment history had not been explored”
leadership
1 finding
minor“Most relatives were unclear about who the registered manager was. One person told us, 'I don't know who the registered manager is, and I haven't met them.'”
end of life care
1 finding
minor“Not all care plans outlined peoples end of life wishes.”