critical“Three of the four care plans reviewed were for people that were at risk of falls. There were no falls risk assessments in place to advise staff on how to minimise this risk.”
critical“Two care plans reviewed were for people that were at risk of pressure ulcers. There were no risks assessments for staff to know how to identify a new pressure area”
moderate“A person who was receiving support with personal care had a catheter. Although staff had received training, there was no catheter risk assessment or guidance for staff”
moderate“For people that were wholly dependent on staff for support with personal care, there were no oral health care plans.”
governance
2 findings
moderate
“medicines audits did not always clarify whose medicines records had been reviewed.”
critical“systems were either not in place or robust enough to demonstrate safety was effectively managed or that there was consistent oversight of the service.”
record keeping
2 findings
moderate“none of these contained references that were signed for or had the company stamp of the previous employer and referee.”
moderate“Daily notes were not personalised and there were often entries such as 'tasks completed, service user comfortable'.”
staffing levels
1 finding
minor“scheduled rosters did not always allow enough travel time for staff to get between calls; and accommodate traffic.”
other
1 finding
critical“recruitment checks were not robust enough to demonstrate thorough consideration prior to being employed. This placed people at risk of harm.”
person centred care
1 finding
critical“The new care planning system had very little personalised detail for staff to understand people's individual needs. There were no life histories or details of people's hobbies and interests.”
end of life care
1 finding
moderate“People's care files lacked end of life support plans. The registered manager confirmed that this is something that she has not yet addressed”