Working at Royal Park

Risks like catheter fluid charts and blood sugar checks not always monitored or followed, putting people at higher risk of harm.

Individual risks to people were not always managed in a safe way. For example, when people had catheters in place their fluid input and output was not being monitored. Although the nurse on duty was aware of this, these were not consistently being documented.

Disorganised records and systems make it hard and slow to find key care info when you need it.

Some of the systems in place lacked organisation and clarity... In one paper file it was recorded when their catheter had last been changed. The clinical lead had to sort through the electronic care plans... No one was able to tell us the date when this was due.

Weak management oversight misses problems like missing capacity assessments and poor audits.

The audits completed had not identified all areas of concerns, for example there was no audit completed that covered MCA, so it had not been identified capacity assessments and best interest decisions were not in place for people.