critical“Care plans and risk assessments did not contain all the information needed by staff to keep people safe. Information and guidance from healthcare professionals was not included in people's care plans and risk assessments.”
care planning
1 finding
critical“Instructions for staff about how to manage risks around choking and swallowing were included in people's risk assessments but not their care plans. Guidance from speech and language therapists was not reflected accurately.”
governance
1 finding
moderate“Quality assurance systems and processes had not identified the concerns with care plans, risk assessments and mental capacity assessment records we found at inspection.”
consent capacity
1 finding
moderate“Records did not always show the provider applied the principles of the Mental Capacity Act 2005 (MCA) consistently. Records of mental capacity assessments and best interests decisions did not all use the same format.”