critical“People's medicine administration records (MAR) were not always clear regarding whether a medicine had been administered.”
critical“Staff had regularly used the wrong code on MAR to record if a person had refused their prescribed medicine.”
care planning
2 findings
critical“Risk assessments were not always in place or did not always contain the relevant strategies to ensure staff understood how to mitigate the risks identified.”
moderate“Not all care plans contained detailed information. We found information was lacking regarding people's health or mental health needs.”
missed or late visits
1 finding
moderate“Records evidenced staff were not always staying with people for the allocated time and we received mixed views from people and relatives regarding staff time keeping.”
staff training
1 finding
moderate“we found no evidence of staff receiving training in mental health, epilepsy or diabetes and people required support with these needs.”
governance
1 finding
critical“The provider had failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.”
record keeping
1 finding
moderate“Records of people's injuries did not always contain the size, shape or colour of the injury.”
person centred care
1 finding
moderate“We found two records for a person that described them using language which was not respectful or person centered.”
cultural competency
1 finding
minor“specific information when a person did not speak English had not been recorded. For example, key phases or words in the person's native language”