critical“risk assessments... were not detailed enough and did not identify individual risks or mitigating actions required for staff to take to help keep people safe”
critical“for one person who had a pressure sore, there was no information recorded to identify risks associated with repositioning, personal care and what the signs staff needed to be aware of”
moderate“Care plans just stated to use a slide sheet or other equipment but not how this was done.”
governance
2 findings
critical“Audits were not effective. Not all records had been completed and there were missed opportunities to improve the quality of care.”
moderate
“care plan audits did not review if there was sufficient detail in care plans or if risks assessments were suitable and sufficient to help keep people safe”
staff training
1 finding
moderate“the registered manager checked that staff were competent to use equipment, but they had not had formal training to assess that staff used this correctly”
medication management
1 finding
moderate“where the position of skin pain patches needed to be recorded, staff had not recorded this. Relatives told us staff varied where they applied the skin pain patches.”
record keeping
1 finding
critical“Not all records had been completed or kept up to date. Staff did not always have accurate records they could rely on to provide good quality care.”
leadership
1 finding
moderate“the registered manager provided care to people where a female member of staff was requested. This detracted from the governance and oversight of the day to day running of the service.”