moderate“the registered manager did not have a system in place or audit-trail to check that care planning documentation was accurate and up-to-date and complied with regulations.”
minor“there was not a system to analyse the data for trends which is important in order to review whether procedures are effective.”
record keeping
1 finding
minor“one person's needs were recorded in the electronic care planning documentation as 'personal care three times a day' but did not specify the person's wishes or support requirements.”
care planning
1 finding
minor
“one person's score was on the threshold for needing further interventions...this outcome was not clearly recorded in the person's care plan.”
consent capacity
1 finding
minor“The service had a mental capacity assessment pro-forma which followed the MCA code of practice. This did not include a best interest process.”