critical“Risk management plans did not always include information for staff to keep people safe. Some people were transferred using a hoist. However, risk management plans did not inform staff of which sling hoops to use.”
medication management
1 finding
critical“Medicine administration records (MARs) did not always direct staff as to the maximum safe dosage of 'when required' medicines in a 24-hour period.”
governance
1 finding
critical“Quality checks of medicines...failed to identify where improvements were needed. A person's MAR for a prescribed medicine to be given daily was blank for the whole of March 2023.”
incident learning
1 finding
critical“We identified two incidents that had not been reported to us as legally required. The nominated individual explained they had believed another manager had sent these to us.”
record keeping
1 finding
moderate“Quality checks on care record completion did not always identify areas for improvement. Care staff had scribbled out a mistake instead of crossing it through or had left blank lines between entries.”
end of life care
1 finding
moderate“Two people were described as receiving palliative care but had no palliative or end of life care plan in place to reflect their wishes had been discussed with them.”
consent capacity
1 finding
moderate“One person's care plan stated they were unable to retain information to make decisions...however, no further detail was given to staff about who could make such decisions on behalf of this person.”
staff competency
1 finding
moderate“Improvement was needed in the processes for assessing staff's medication competency. Whilst assessments had deemed care staff as competent, the knowledge of the assessor required improvements.”