critical“People had no mental capacity assessments or best interest decisions completed...Key requirements of the Mental Capacity Act 2005 were not fully understood by staff.”
moderate“People's mental capacity had been considered but further work was needed to ensure capacity assessments were decision specific.”
medication management
1 finding
critical“Staff did not always record administration of medicines properly...we saw gaps in people's medicine administration records (MARs).”
care planning
1 finding
critical“1 person lived with a complex condition...The risk assessments and care plan for this person were contradictory and did not provide staff with clear guidance.”
governance
1 finding
critical“Audits of people's care plans did not identify that they were not always comprehensive or up to date...risks were not always identified or managed appropriately.”
record keeping
1 finding
moderate“Provider's systems did not identify all shortfalls in recording of people's care...staff did not always record their interactions and support for the person correctly.”
staff training
1 finding
moderate“"Training is not really sufficient. Not compared to the past. Some are more able than others...They're nice [carers] who would make good carers with more training."”
communication with families
1 finding
minor“People and their relatives gave us mixed feedback about communication with the management team...others told us that it needed improvement.”