moderate“Information in relation to two people's catheter care needs was not included in their care records... no specific instructions for how care workers were expected to meet their catheter care needs.”
minor“No specific information recorded about what care workers were required to do in assisting the person... people at risk of not having their needs met if seen by care workers who were new to them.”
minor“there was very little advice within care records about what people's likes and dislikes were in relation to food which would help to ensure that care workers met people's individual needs”
medication management
2 findings
critical“Care records did not contain a written record of what medicines people were supposed to be taking, the method of administration and the dosage, frequency and times.”
moderate“in one care plan we reviewed, we found there was not a full list of the medicines the person was supposed to be taking...the dosage of medicines the person was supposed to be taking was not recorded”
incident learning
1 finding
critical“Two incidents relating to one person which had not been responded to appropriately... registered manager had not spoken to any healthcare professionals about this person's needs.”
record keeping
1 finding
moderate“Two people were identified as being at risk of developing a pressure ulcer, however there were no risk assessments in place.”
governance
1 finding
moderate“Quality monitoring systems did not prompt the registered manager to appropriately identify and manage the issues we found.”