moderate“Whilst a complaints policy was in place people and relatives did not receive formal responses and outcomes of investigations undertaken.”
care planning
1 finding
moderate“there were no formal arrangements or timescales in place for reviewing people's plans of care. Records showed previous care plan reviews had been sporadic and unstructured.”
consent capacity
1 finding
moderate“mental capacity assessments and best interest decisions required more detail to show how judgements were reached.”
governance
1 finding
moderate“Whilst audits were in place action was not always taken when shortfalls were identified... these actions had previously been identified in April and May 2022 audits.”
record keeping
1 finding
minor“The audit also identified several other actions including improvement needed to recordings of daily notes.”
leadership
1 finding
moderate“This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”