critical“Risk assessments lacked the detail required to effectively mitigate risks.”
medication management
1 finding
critical“There was insufficient information about people's medicines in people's care records to ensure they were supported to take them in a safe way.”
governance
1 finding
critical“The registered persons failed to effectively operate systems to assess, monitor and improve the quality and safety of the services provided.”
consent capacity
1 finding
moderate
“Mental capacity assessments were not always accurately completed and did not clearly demonstrate if the person had capacity to consent to care and treatment.”
person centred care
1 finding
moderate“Support plans we reviewed were mostly brief and did not contain sufficient information such as detailed likes and dislikes, choices, and preferences.”
record keeping
1 finding
moderate“Some people's care records stated they lacked capacity to make decisions... people's care files did not always have required documentation to confirm that relatives were legally appointed.”
staff competency
1 finding
moderate“Weekend staff and staff who were not regular to them did not always know the needs of the person.”