critical“Not all care plans contained enough detail about how staff supported people safely. A person's pressure care needs were not risk assessed, care plans did not contain detail about how staff safely transfer this person.”
medication management
1 finding
critical“Some MAR's were not completed appropriately, meaning we could not be assured people received their medicines as prescribed. PRN protocols were not in place to guide staff about how and when to give these.”
governance
1 finding
critical“Audits had not identified concerns found during the inspection in relation to care records, capacity and consent, medicines records and staff training.”
incident learning
1 finding
moderate“Systems to monitor accidents and incidents were not always effective and did not promote learning, to reduce the risk of reoccurrence and improve the quality of the service.”
consent capacity
1 finding
moderate“Records were not clear about people's capacity to consent and did not contain capacity assessments or best interest decisions.”
staff training
1 finding
minor“Further training was required to ensure all staff completed The Care Certificate.”