moderate“there was no policy guidance or written procedures in place to guide staff in the application of the MCA, which includes a 'best interest' approach.”
moderate“there was no provider assessment in place to assess people's capacity to make informed decisions about their day-to-day care.”
incident learning
1 finding
moderate“analysis did not allow for the identification of themes and trends upon which action could be taken”
governance
1 finding
moderate“analysis was not undertaken on the themes and trends across all accidents and incidents. This did not allow the registered manager to address potentially larger and more complex concerns”