critical“Medicines were not always managed safely or in line with good practice guidance. We found gaps in medication records and medication was not always recorded individually.”
governance
1 finding
critical“Medication audits provided had not identified the issues found during this inspection. Systems were either not in place or robust enough to demonstrate effective oversight.”
record keeping
1 finding
moderate“Care records were not always complete or contemporaneous. People's communication plans were not always recorded.”
consent capacity
1 finding
critical“Mental capacity assessments were not consistently recorded. The provider was not always following their own policies and best practice guidance in relation to the MCA.”
care planning
1 finding
moderate“Most care plans were centred around people's needs and preferences however, these did not always follow best practice guidance, and some required additional detail.”
staff training
1 finding
moderate“Not all staff had received training to care for people at the end of their lives or around compliance with the Mental Capacity Act.”
staff competency
1 finding
moderate“Staff had not always completed a medication competency assessment as frequently as recommended in good practice guidance.”
end of life care
1 finding
moderate“People's care plans did not always detail people's particular end of life care wishes. Not all staff had received training for caring for people at the end of their life.”