critical“Systems or processes were not established and operated effectively to assess, monitor and improve the quality and safety of the services.”
care planning
1 finding
critical“risks to two people's health in relation to hydration were not identified or mitigated... a daily fluid target was not identified”
other
1 finding
critical“Fire risk assessments, emergency evacuation procedures and fire drills did not effectively identify or mitigate hazards and did not account for reduced staffing levels at night.”
medication management
1 finding
moderate“PRN protocols were not always in place and where they were, these were not always person specific to ensure effective, consistent administration of medicines.”
record keeping
1 finding
moderate“information in people's care records were not always accurate, contemporaneous or complete. Information in different documents were not accurately cross referenced.”
staff training
1 finding
moderate“We found there were still gaps in training for existing staff across all areas. The current training matrix did not always account for staff initial training”
consent capacity
1 finding
moderate“the decisions being assessed were not always specific and the best interest decision had not been recorded.”
incident learning
1 finding
moderate“insufficient action was taken in response to a person's hospital treatment for presumed urinary tract infection (UTI) and acute kidney injury to ensure appropriate monitoring systems were agreed”
person centred care
1 finding
moderate“recorded care plans did not always provide clear information about people's specific needs or support requirements... 'full support with personal care' was used without explanation”
communication with families
1 finding
minor“people's care plans contain accurate information about identified needs and preferences... one person's care plan did not include the use of pictures, shorter words or videos”
safeguarding
1 finding
minor“one instance where a staff member had not completed the correct record for an unexplained injury, which meant this was not escalated appropriately.”