critical“Systems to assess and manage risks had not ensured complete and accurate records were available to guide staff on how to ensure people's safety.”
safeguarding
1 finding
critical“We could not be assured the risks had been considered... placing the individual at risk of harm. Breach of regulation 12 (Safe Care and Treatment).”
governance
1 finding
moderate“The systems used to audit the service had not identified issues we had found regarding managing risks to people's safety.”
leadership
1 finding
moderate
“Over the years it was very good... Then [with the] changes, I found care seemed to go down. The good manager left, and the dynamics changed.”
communication with families
1 finding
minor“Communication is deteriorating. The last manager left. [They were] good with residents. The manager now covers five homes.”