moderate“In two care records, we noted a relative had signed consent and we did not see any record of such [legal authorisation] in their files.”
minor“We noted one person may have required a review around the extent and level of supervision the service was providing to ensure compliance with legislation.”
record keeping
2 findings
moderate“Some records did not document what follow up action, if any, had been taken... instances where a body map should have been completed and had not been.”
minor“Although the registered manager routinely assessed people's capacity and held best interest discussions with key people, this was not always formally documented.”
incident learning
1 finding
moderate“No formal analysis of incidents had been done so we could not easily identify trends or patterns regarding these incidents.”
medication management
1 finding
moderate“For the fourth incident, we did not see what action, if any, the service had taken to help ensure such incidents were minimised.”
governance
1 finding
moderate“Current audit systems did not effectively identify the issues we found at this inspection such as gaps in accident and incident reporting, incomplete incident forms.”
complaints handling
1 finding
minor“The minutes contained no details of the issue, the discussion and how the matter had been addressed... detailed records had not been kept.”
staff competency
1 finding
moderate“Safe recruitment procedures were not always followed. We found checks into staff members' histories had not been thorough enough. Some checks with previous employers in health and social care had not always been made.”