moderate“two different versions of the electronic log in use, and some managers had been logging required updates on the wrong version in error”
minor“Not all people's care plans were in this format. This did not impact on people's care and support as staff were fully aware of individual needs.”
governance
1 finding
critical“quality assurance processes were not sufficiently robust to assess, monitor and improve the quality of the services provided — breach of Regulation 17 (2)(a)(b)”
incident learning
1 finding
moderate“an example of an incident recorded in the hard copy accidents and incidents file that had not been added to the electronic log, so the manager of the service involved was not aware”
supervision appraisal
1 finding
minor“Not all staff had received supervision from their line manager in the last three months, but plans were in place to address this”
consent capacity
1 finding
minor“not all staff had received training in relation to the mental capacity act… records in relation to this could be clearer in some cases”
medication management
1 finding
minor“the registered provider did not routinely have protocols in place for other types of medication that may be prescribed for use on an 'as required' basis, such as creams”
end of life care
1 finding
minor“We did not see evidence of end of life arrangements in place for people within the service. Discussion held with house leaders identified this was an area to be improved upon.”