critical“Electronic medicines administration records (MARs) did not consistently provide a full, accurate and contemporaneous record of administration.”
record keeping
1 finding
critical“Some risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient detail to help staff understand and respond to risks.”
infection control
1 finding
critical“Systems were not operated effectively to ensure appropriate infection control measures. This was a breach of Regulation 12(1)(2).”
governance
1 finding
critical“Governance systems did not effectively assess, monitor or improve the service to ensure compliance with all required regulations. This was a breach of Regulation 17(1)(2).”
care planning
1 finding
moderate“Care plans included varying levels of personalisation about people's care needs...desired outcomes lacked meaningful personalised detail about what people aimed to achieve.”
incident learning
1 finding
moderate“Completed accident and incident forms were not an accurate record of all incidents which had taken place...auditing processes of care records had not identified the concerns.”
consent capacity
1 finding
moderate“Some people's care plans contained statements regarding their mental capacity, without evidence of a decision specific mental capacity assessment having taken place.”
staffing levels
1 finding
moderate“Rotas showed staff were not consistently given sufficient travel time, and staff did not consistently stay for the scheduled visit length.”
person centred care
1 finding
minor“The service had not formally documented care plan review discussions where people received ongoing, rather than short-term care.”