moderate“when people were prescribed pain patches, staff did not always record where the patches had been removed from and where they had been replaced. Body maps were not used in line with best practice.”
moderate“When people needed medicines on an 'as and when' basis (PRN), there were no PRN protocols in place. Staff did not follow the provider's PRN policy.”
care planning
2 findings
moderate“some risk assessments lacked detail. For example, when people had a catheter to drain urine from their bladder, there was no information to alert staff to possible signs of infection.”
moderate“Care plans lacked detail about individual health conditions. For example, signs that could indicate a decline in health.”
governance
1 finding
critical“Checks and audits were not consistently robust. Some of the shortfalls found during the inspection had not been identified by the registered manager and management team.”
staff training
1 finding
moderate“Staff refresher training was not up to date. The registered manager had recognised this and was taking action address this.”
staff competency
1 finding
moderate“The process to assess staff competency was not consistently robust. The quality of the assessments varied.”