moderate“We reviewed a best interests decision form for one person which was not decision specific as it listed a number of tasks...There was no record of who was consulted during the best interests decision”
moderate“We found the health risk assessment for one person recorded they did not have a catheter when they did.”
consent capacity
2 findings
moderate“a relative was signing consent forms although they did not have the legal authority to do so”
moderate“The principles of the Mental Capacity Act were not always followed. This meant people were not always supported to have maximum choice and control of their lives.”
care planning
2 findings
critical“Risk assessments were not always robust enough to help reduce the risk of avoidable harm to people. Risks to people had not always been assessed and where risks were identified, a risk mitigation plan was not always completed.”
critical“Care plans not having up to date information meant there was a risk people might not receive appropriate care according to their needs and preferences. This was a breach of regulation 9 (Person centred care).”
medication management
2 findings
moderate“Medicines were generally managed safely, but prescribed creams were not always correctly identified or recorded.”
moderate“One of the medicines was time critical, but guidance around this was not included in the care plan, which meant the medicines may not have been given to the person at the right time to ensure it was effective.”
staff training
1 finding
moderate“DBS checks were not up to date...The staff were employed as part of a sponsorship programme and the registered manager thought they had three months to apply for a DBS.”
governance
1 finding
critical“systems were either not in place or robust enough to demonstrate safety was effectively managed. This was a breach of Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
person centred care
1 finding
moderate“The provider had care plans in place, but these were not always updated appropriately when people's needs changed. This meant care plans were not always personalised to service users' needs.”