critical“Medication records were lacking in detail and the medication audit did not currently cover the service in the community.”
record keeping
1 finding
moderate“Care plans and risk assessments needed expanding to ensure the needs of the people were fully recorded and all risks had been mitigated.”
governance
1 finding
critical“The failure to assess, monitor and improve the quality and safety of the service and to maintain accurate and complete records is a breach of regulation 17(1)(2)(a)(c)”
consent capacity
1 finding
moderate“More detail is needed within the care records to ensure capacity is clearly recorded to help guide staff. The service was reliant on the social care team to guide them in this area.”
care planning
1 finding
moderate“Areas of the care plans needed expanding to include details of all aspects of care and staff responsibility.”