critical“staff were administering the medicines. No medicines administration record (MAR) charts were in place and there was a risk that staff would not administer the medicines safely.”
care planning
1 finding
moderate“Care plans for people who used a catheter or urostomy lacked sufficient detail to ensure consistent care and management of risks.”
record keeping
1 finding
moderate“Not all people's risks had been consistently assessed. We found some people had detailed assessments for pressure ulcers and malnutrition, whilst other people's assessments lacked detail.”
staff training
1 finding
moderate“Staff had not always received training in the needs of the people who used the service, such as catheter, urostomy and dementia care.”
governance
1 finding
moderate“systems and processes were in place to monitor the quality of the care provided; however, these had not always resulted in areas for improvement being identified and acted upon in a timely manner.”
supervision appraisal
1 finding
minor“the manager had begun to implement observations and spot checks for staff, however few staff had received these. This meant the manager could not effectively monitor the care that staff were providing.”