critical“risk assessments were still not in place for all identified risks. There was no specific information on how to monitor the risks associated with catheter care.”
critical“no risk assessment in place for the use of this moving and handling equipment... no catheter care risk assessments, allergies risk assessments or moving and handling equipment risk assessments.”
critical“Care plans did not always provide clear guidance for staff to follow on how to meet people's individual healthcare needs.”
governance
2 findings
critical“auditing systems in place were not robust enough to ensure all records contained the updated documents.”
critical
“The provider's quality assurance systems and processes were not effective. Although a programme of audits was in place, this had not enabled the provider to identify and address the shortfalls”
record keeping
2 findings
moderate“audit was in place for the reviewing of people's daily records, however there was no document to demonstrate the completion of the audit.”
moderate“care plans and risk assessments were not consistently updated as needed to reflect advice from external professionals.”
person centred care
1 finding
moderate“registered manager had put in place a diabetes care plan for 1 person; however, it did not contain enough information to inform staff of how to meet their specific needs.”
safeguarding
1 finding
critical“Some staff we spoke with lacked understanding of their safeguarding responsibilities. For example, one member of staff was unaware of how to report or record safeguarding concerns.”
staff training
1 finding
critical“not all staff had completed first aid training, moving and handling training or pressure ulcer prevention training.”
consent capacity
1 finding
moderate“When a person's capacity to consent to particular elements of their care was in doubt, the provider told us they had not always ensured a mental capacity assessment was completed.”
incident learning
1 finding
critical“one person had developed a serious pressure sore when receiving care from the service. The provider had failed to notify us of this injury.”
end of life care
1 finding
moderate“People's assessments and care plans did not always include information regarding people's end of life wishes. The provider told us they would not normally ask about people's end of life preferences.”
staff competency
1 finding
moderate“I feel [staff] should have more training and shadowing.”