critical“Care plans and assessments did not comprehensively identify, assess and detail people's physical, mental and emotional health needs and support.”
record keeping
1 finding
moderate“A care plan referred only to the person by their initials throughout and referred to the person at times as different sexes for example he/she.”
governance
1 finding
critical“The registered manager confirmed that there were no audit systems in place to check care records, risk assessments, care plans, staff files and staff recruitment.”
staff training
1 finding
moderate“There was no formal training programme in place or a formal induction process for new staff and this required improvement.”
medication management
1 finding
moderate“Systems in place for managing and administering people's medicines were not safe... medicines care plans, risk assessments, MAR and medicines audits [were absent].”
staffing levels
1 finding
critical“Staff records were disorganised and did not contain relevant checks undertaken such as staff applications, interviews and references.”
person centred care
1 finding
moderate“People's care was not consistently personalised as care plans did not always identify and or reflect individuals' preferences, life histories, social networks, interests and hobbies.”
consent capacity
1 finding
moderate“The service did not have systems in place to work within the principles of the MCA... assessment tools to assess people's capacity to make specific decisions were not in place.”