minor“Relatives confirmed they were involved in care decisions, but their involvement or legal authority to act was not always recorded.”
critical“People's capacity and ability to consent to particular decisions was not always assessed or recorded... not all people had capacity to give informed consent.”
critical“DoLS were not always in place when required and were not always renewed when they expired.”
governance
2 findings
critical“Quality assurance within the service was ineffective. The provider's internal audits had failed to identify the issues found during this inspection.”
moderate
“A number of issues were identified following a health and safety audit. There was no evidence of recommendations, actions taken, and lessons learned being recorded.”
record keeping
2 findings
critical“When best interests decisions were made on behalf of people who lacked capacity, these decisions were not documented.”
moderate“Repositioning was not recorded and so we could not be assured this was taking place.”
medication management
1 finding
minor“Some records for people who required medicines as and when needed lacked detail about how staff would recognise when these were required.”
care planning
1 finding
critical“Care plans and risk assessments did not always reflect people's current needs or provide appropriate guidance for staff.”
incident learning
1 finding
moderate“Accidents were reviewed for overall trends but it was not always clear whether lessons had been learned and whether actions had been implemented.”
communication with families
1 finding
minor“The provider did not always engage and involve people, relatives and staff in an effective way. There were limited opportunities for people, relatives and staff to provide meaningful feedback.”