critical“Where people had a healthcare condition, there was not always enough detail about this to ensure staff knew how to identify and reduce risks relating to these.”
critical“the risk management plan gave only basic guidance which did not include proactive strategies. There was no assessment or guidance for managing the risks for the other person.”
governance
1 finding
critical“The provider's systems had not always identified, assessed or mitigated risks to people's safety and wellbeing.”
record keeping
1 finding
moderate“The provider's systems did not always ensure that accurate and complete records were in place.”
incident learning
1 finding
moderate“some of the information in care records was unclear and needed more detail for staff to fully understand their needs, information about the medicines people were prescribed and capacity to make choices.”