critical“People's care plans did not include people's preferences on how they would like to be supported with personal care such as with bathing, showering and continence.”
moderate“Some care plans were not updated following change of circumstances. Two people's support needs had changed, however this was not accurately reflected on the care plan.”
medication management
1 finding
critical“MAR showed a number of gaps on 2 people's MAR with no information on why these medicines were not administered, which meant there was a risk these medicines were not given”
record keeping
1 finding
critical
“Daily notes showed records that medicines had been administered but did not detail which medicines had been administered therefore we could not be assured all medicines had been administered safely.”
governance
1 finding
critical“We did not see evidence that systems were in place to carry out audits on care plans, which meant shortfalls we found with care plans, communication plans and risk assessments could not have been identified.”
person centred care
1 finding
moderate“Pre-assessments and reviews had been carried out this did not include people's preferences with the support they required to ensure people were safe at all times.”
communication with families
1 finding
moderate“Communication plans were not in place and did not include how staff should communicate with people. A person told us, "They don't understand me and I don't understand them."”