critical“some people's care plans and risk assessments were inconsistent and sometimes lacked information.. For example, in one person's care record we found inconsistent records kept with regard to whether the person smoked.”
record keeping
1 finding
critical“incomplete or inconsistent record keeping that could have placed people at risk of avoidable harm.”
consent capacity
1 finding
critical“care records that were not signed by the person using the service...no indication within the records about whether the person had the capacity to make this decision.”
governance
1 finding
critical“did not see evidence of audits or any other monitoring of care records...provider was not assessing, monitoring or mitigating the risks we found to service users.”
safeguarding
1 finding
critical“We identified two safeguarding incidents that had not been reported to CQC as required so that these could be assessed and action taken where appropriate.”
supervision appraisal
1 finding
moderate“appraisals were not conducted regularly...some staff had not had an appraisal for over two years.”
person centred care
1 finding
moderate“care records contained very limited details about people's needs or preferences...very limited or no information about people's life history or preferences in relation to how they wanted their care to be delivered.”
medication management
1 finding
moderate“any discrepancies in recording or any errors in the administration of medicines may not have been identified or addressed for a significant period of time after the incident occurred.”