minor“The provider had not always recorded in enough detail whether a person had someone appointed to act on their behalf when they lacked capacity to make a decision”
minor“Individual care plans were often not dated so this made auditing case files difficult”
consent capacity
1 finding
moderate“these lacked sufficient detail and did not follow national guidance such as specifying the decision required...not a decision specific mental capacity assessment”
care planning
1 finding
moderate“individual risks had often not been assessed and mitigated for in people's care plans”
safeguarding
1 finding
critical“the service did not always notify the appropriate authorities of safeguarding incidents and their outcomes as required and was not sufficiently aware of this duty”
incident learning
1 finding
moderate“there was not a structured recording or systematic analysis process to ensure 'lessons were learnt' and incorporated into practice”
governance
1 finding
moderate“Audits were not always systematically managed or recorded to ensure accurate records, analyse practice or drive improvements”
staff training
1 finding
moderate“Training records were not clear that all staff were receiving training in all core subjects and showed that not all staff were receiving regular refresher training”
supervision appraisal
1 finding
minor“Whilst the provider was not completing formal appraisals they were able to show that they were monitoring staff competencies and supporting staff development”
medication management
1 finding
critical“The registered manager had not notified the local authority safeguard team and Care Quality Commission of the medicines administration errors as required by regulations”