moderate“We found the policies and procedures did not routinely reflect best practice...were not routinely dated, did not have page numbers or version control.”
moderate“We found not all decisions and discussions about people's care was recorded...the conversation...held with the GP...had not been recorded.”
governance
2 findings
moderate“The application form used by the service did not always provide all of the requirements...the service did not routinely record a reason for staff leaving previous employment.”
minor“We found risk assessments were not routinely dated...Other records which had been scanned onto the electronic system did not always contain names of people or page numbers.”
staff training
1 finding
minor“Not all staff had completed the Care Certificate...widely accepted as good practice.”
consent capacity
1 finding
moderate“Some records referred to decisions being made in the person's 'best interest' however other documents referred to the person as having capacity to consent.”