critical“Risk assessments did not always include enough information for staff about people's known areas of risk.”
minor“care plans did not include people's personal history to enable staff to have a better understanding of the person. The registered manager told us they would add this.”
minor“information was not as detailed for 'how' staff should safely manage the risk and recommended the risk assessments had more detailed information added in this area.”
medication management
2 findings
critical“Medicine administration records (MAR) contained gaps which were not picked up during audits.”
critical
“There was no guidance for staff to follow when people had medicines to be taken 'as required.'”
record keeping
2 findings
critical“When people made a decision about DNACPR...this information was not stated in their care plan.”
minor“We suggested that more personalised information such as, people's emotions, interactions and outcomes would further develop these records.”
staff competency
1 finding
moderate“Staff files we looked at contained gaps in staff employment histories and the reasons were not explored during the recruitment process.”
consent capacity
1 finding
moderate“MCA assessments were not carried out to document people's decision making abilities or any support they needed in this area.”
governance
1 finding
moderate“Audits of care records did not pick up the concerns we found about the lack of information and guidance for staff.”
supervision appraisal
1 finding
minor“Staff also received one to one supervision sessions which were scheduled 6 monthly. The registered manager agreed more regularly was likely to be beneficial.”