moderate“there were not always detailed, individual care plans in place. For example, when people had health conditions or periods of emotional distress.”
moderate“Care plans and risk assessments were not always reviewed to reflect the changes made in response to incidents”
governance
2 findings
critical“Systems in place were not robust to ensure people were protected from harm. This was a breach of regulation 17 of the Health and Social Care Act 2008.”
moderate“audits had not identified all the areas requiring improvement that we identified during our inspection.”
missed or late visits
1 finding
moderate“one person told us, 'I have to call out of hours. 1 or 2 hours late.' Another person told us, 'Once or twice not turned up.'”
consent capacity
1 finding
moderate“People did not always have capacity assessments in place that were specific to the decision being made.”
medication management
1 finding
moderate“'As required' medicines did not always have clear guidance for staff to follow to support them to administer these medicines safely.”