critical“Both people's records said they were at risk of falls and pressure sores, but there were no specific risk assessments identifying the level of risk and there were no clear written guidelines”
person centred care
1 finding
critical“people's care plans included some personalised information about their life histories and personal circumstances, but there was little recorded information about their specific needs and preferences”
governance
1 finding
critical“The provider was not conducting audits of the care provided. The registered manager did not always demonstrate a good understanding of regulatory requirements”
medication management
1 finding
moderate“The provider had a record of which medicines people were taking, but there was insufficient information about whether there were any side effects to these and what they were for.”
leadership
1 finding
moderate“the registered manager did not fully understand regulatory issues relating to risk management, which meant he did not identify the issues we found.”
record keeping
1 finding
moderate“people's care records listed their current health conditions as well as the history of their health needs, but there was no recorded information about how these affected people.”
other
1 finding
minor“the provider had requested a DBS check from the care worker, but had accepted a check that had been conducted one year ago. This meant the provider could not be sure they had the full history”