moderate“Risk assessments were not always in place to manage risks within people's lives. Risks had been identified by staff, but had not been documented.”
record keeping
1 finding
critical“Systems and processes were not always in place to ensure that documentation was thorough and complete across the service.”
medication management
1 finding
moderate“There was not always sufficient documentation for medicines required on an as and when basis (PRN). Information about when and why PRN medicines were in place was not detailed.”
consent capacity
1 finding
moderate“Sufficient documentation had not always been completed to assess people's capacity to make decisions... There had been no formal mental capacity assessment.”
person centred care
1 finding
moderate“Care plans did not always reflect people's personal history, likes, dislikes and preferences.”
governance
1 finding
critical“This lack of effective oversight put people at the increased risk of harm. This was a breach of regulation 17 good governance of the Health and Social Care Act 2008.”