moderate“Shortfalls were found in people's care plans, where people had known risks, they were not identified and mitigated through risk assessments.”
governance
1 finding
critical“Systems were either not in place or robust enough to demonstrate good governance. This placed people at risk of harm. This was a breach of regulation 17.”
incident learning
1 finding
moderate“Processes were in place to ensure accidents and incidents were recorded but these had not been analysed or audited to look for patterns or trends.”
staff training
1 finding
critical“We identified a care worker who was administering medicines without the correct training or competence check.”
staff competency
1 finding
moderate“Not all staff had completed all training modules... other staff said their induction was minimal.”
record keeping
1 finding
moderate“Positive behaviour support plans were not in place for people. Where we identified people who express their feelings through heightened emotions, plans to support them were not in place.”
consent capacity
1 finding
minor“Mental capacity assessments were not completed for decisions relating to people's care or treatment.”