moderate“improvements, and actions from the audits, did not feed in to an overall action plan for the service. This meant it was hard to establish and monitor what actions needed to take place, by who, and when.”
medication management
1 finding
moderate“Audits of medicines were not regularly taking place... The service was not regularly carrying out competency checks.”
end of life care
1 finding
minor“The service had not discussed or planned for end of life care. There were no records of people's wishes and views on this subject.”
record keeping
1 finding
minor“systems did not easily support the 'live' updating of care plans as two separate paper copies...were being used and this increased the risk of potential errors.”
incident learning
1 finding
critical“We found one safeguarding incident had occurred in the service which we had not been notified of. The service had notified other relevant parties but had omitted to notify us.”
staffing levels
1 finding
minor“Recent changes within the staff team meant at times the service had to use agency staff...some staff felt at times this had placed an additional pressure on them.”
consent capacity
1 finding
moderate“in the absence of mental capacity assessments, it was not clear how the level of people's mental capacity was assessed or how they were supported in making decisions.”