moderate“Risk assessments did not always detail the measures in place to mitigate risk to people. Whilst care plans were in place, further guidance was needed for staff.”
governance
1 finding
critical“Systems were not robust enough to demonstrate effective monitoring of the quality of the service. This was a breach of Regulation 17 (Good Governance).”
record keeping
1 finding
moderate“People's care records did not consistently reflect the knowledge staff and the management team had about people's preferences for care.”
consent capacity
1 finding
moderate“Where people had been deemed to lack capacity to make the decision, a best interest decision record had not been made.”
communication with families
1 finding
minor“Detail of these visual aids were not always recorded in people's care plans. Doing this would ensure all staff were aware of the use of aids to support communication.”