moderate“Audits had not identified the shortfalls we found during the inspection, which included medicine and decision-making records.”
minor“some of these had not been recorded. The service would benefit from recording all results of audits and developing action plans in order to learn and develop.”
governance
2 findings
minor“The provider had developed a new governance system to promote quality and consistency across their services. We were informed the system would be implemented following the inspection.”
minor“The visits took place on different days and at different times. They checked records, observed care support...These visits had not been reported upon.”
medication management
1 finding
moderate“Medication monitoring systems had not identified or addressed all shortfalls. Systems had not identified some hand-written medication records had not been signed by two staff”
consent capacity
1 finding
minor“Some decisions had been incorrectly recorded as best interest decisions. We discussed processes for appropriately recording these decisions with the manager.”
person centred care
1 finding
minor“The care records would benefit from including more pictorial information to better enable people's involvement.”