critical“one person at risk of pressure sores due to their health condition had no risk assessment or care plan in place to provide information to care staff on how to mitigate this risk.”
medication management
1 finding
critical“One person received support with a medicine that care staff had not had the specialist training to administer. This placed people at risk of harm.”
staff competency
1 finding
critical“Care staff had not received training in catheter care, tissue viability and diabetes awareness.”
consent capacity
1 finding
critical“mental capacity assessments had not always been completed and best interest decisions recorded.”
governance
1 finding
critical“Systems to review and audit medicines administration were not in place to identify shortfalls...We found records of missed medication for two people that had not been identified by the registered manager.”
record keeping
1 finding
moderate“During the inspection we identified missing or incomplete risk assessments for risks relating to pressure care, fire and moving and handling.”
end of life care
1 finding
moderate“People's care plans did not inform staff whether people had a 'Do not attempt cardiopulmonary resuscitation' [DNACPR] in place or not.”
person centred care
1 finding
moderate“Peoples care plans were found to contain generic and limited information.”
staff training
1 finding
moderate“Staff had not received training in diabetes, catheter care, pressure care and interacting with autistic people and people with a learning disability.”