moderate“The registered manager did not always capture incidents relating to restraint and how any lessons learnt that is identified is shared with the relevant people to drive change and improvements.”
safeguarding
1 finding
critical“we found examples where staff did not follow these guidelines and it resulted in people being unnecessarily restrained and, in some cases, not in line with safe practices.”
medication management
1 finding
moderate“Records and trends picked up by the management team showed that there were consistent areas of improvement in the signing of the medicine administration records.”
care planning
1 finding
moderate“In some cases, there were restrictions in people's homes without adequate justification as to if this was the least restrictive measure.”
communication with families
1 finding
minor“Professionals spoke highly about the responsiveness of staff, however they felt that the communication with the management needed to improve.”
governance
1 finding
minor“the registered manager was going to develop the system they already had and incorporate these areas into themes and trends to drive change.”