Working at Chestfield House

Risk guidance in care plans often missing or wrong, like no info on catheter changes or blood sugar checks, so staff unsure how to keep people safe.

Potential risks to people's health and welfare had not been consistently assessed. There was not detailed guidance available for staff to mitigate the risks and some care plans were not accurate.

Medication records inaccurate and unclear rules on giving as-needed painkillers or anxiety meds, risking wrong doses.

Medicines were not always managed safely. Some people had been prescribed medicines on a 'when required' basis... There was not clear guidance about when to give these medicines... Records of medicines administered were not accurate.

Manager's audits and checks missed key problems like poor care plans, so issues build up without fixes.

Checks and audits... had not been effective at identifying the shortfalls found at this inspection... The registered persons had failed to effectively assess, monitor and improve the quality of the services provided.