critical“Care plans were not always kept up to date and contain sufficient up to date guidance for staff to follow to keep people safe.”
governance
1 finding
critical“The provider's oversight systems and processes were not effectively used to monitor the quality of service being provided and to drive improvements.”
incident learning
1 finding
moderate“Accidents and incidents were analysed individually, however there was limited oversight to identify any trends.”
record keeping
1 finding
critical
“A body map detailed the different sites where the skin damage had occurred, but these were not dated nor detailed any follow-up actions.”
staff training
1 finding
moderate“The training matrix highlighted where staff training was due to expire or had expired. Training was booked for some staff but not all.”
medication management
1 finding
moderate“Staff had recorded medicines were prompted despite no reference made in the care plan.”
person centred care
1 finding
minor“A person's religion and culture was not accurately reflected. This was raised with the registered manager and they agreed to follow this up.”