moderate“Not all care documents reviewed listed people's gender preferences when being supported with personal care. This created a risk that people may not be being supported by those who they would choose.”
moderate“Regular meetings with people supported were not taking place at the time of the inspection.”
minor“these monthly meetings had not always occurred and that there were a number of gaps. We saw in one person's records that the last three meetings had been held in October and December 2014 and February 2015.”
care planning
2 findings
moderate“Care plans were currently undergoing a review, causing some of the information recorded to not be of the standard we would expect.”
moderate
“Overall reviews of care plans were not recorded in detail and it was not clear where any changes to care had occurred as there was only a date and signature and 'no change' recorded.”
record keeping
2 findings
minor“There was no record to indicate where on the body the patch had been applied, causing a potential risk that this item would not be applied as per manufacturer's instructions.”
minor“risk assessments were not always cross referenced to the care records and details were not always clear or up to date.”
communication with families
1 finding
minor“Feedback from families was mixed in relation to communication. Some families had maintained regular communication with the service where others felt this was an area that required development.”
governance
1 finding
moderate“Progress had been made but due to unforeseen reasons the progress had not been as extensive as the registered manager wanted and changes had not become fully embedded.”