critical“one person had a suprapubic catheter in place and staff supported them with changing the urine bags...However, there was no care plan in place to guide staff on how to support this person.”
record keeping
1 finding
critical“one person had been discharged from hospital and their care increased from two to four visits per day...the person's care plan had not been reviewed and updated to reflect the changes.”
governance
1 finding
critical“no medicine or care plan audits had been completed. The concerns we found in records had not been identified. Risks to people were not always identified or managed.”
incident learning
1 finding
moderate“there was no system in place to audit or analyse accidents and incidents to look for trends.”
safeguarding
1 finding
critical“one person coughed during meals and drinks, which indicated they were at risk of choking. However, there was no risk assessment or risk management plan for choking in place.”
consent capacity
1 finding
moderate“we found no evidence to show that people's consent was always sought for information sharing or involvement in care planning and reviewing.”
staff training
1 finding
moderate“staff knowledge in relation to the MCA varied..."I don't know what that is"...Records showed staff had not received training in the MCA.”