moderate“Audits had not been completed on staff files to ensure they contained all of the required information.”
moderate“Audits of some records needed to be more robust to ensure they identified areas for improvement.”
moderate“these audits had not identified concerns such as gaps in recordings...other audits had been recorded as completed when there was no related information within the file”
record keeping
2 findings
moderate“Recruitment checks had been completed but formal records to support the checks undertaken were not in place.”
moderate
“there were some gaps within the charts which had been left blank...details of complaints dealt with were not comprehensive and only included a brief detail”
medication management
2 findings
moderate“Audits...did not identify and explore the reason for gaps in medicine charts, or when staff had recorded an incorrect time on the daily records.”
moderate“staff members did not consistently utilise the coding system for whether medicines had been given. For example, one person's medicine had been discontinued but this had not been recorded.”
care planning
2 findings
minor“Care records reviewed varied in detail with some being more person centred than others.”
moderate“a person who was noted in their care plan as having ulcerated skin did not have a related risk assessment in place. Another person who used a catheter, had no guidance in place”
staff training
1 finding
moderate“one [recruitment file] did not include two references to ensure that the employer had sufficient information to assess the employees suitability.”
leadership
1 finding
moderate“There was not a registered manager in place and there had not been since July 2017.”
end of life care
1 finding
minor“care plans did not include information related to people who wished to continue receiving care at home towards the end of their life. No discussions had taken place”
infection control
1 finding
minor“We did not see any information relating to infection control, particularly relating to areas where good hygiene was required, such as catheter care and food preparation”
complaints handling
1 finding
minor“The complaint was not dated, which made analysing timescales of action taken difficult and there was no information given on how the outcome of any investigation had been shared”