critical“People did not always have mental capacity assessments for restrictive interventions and it was not always clear if decisions made were in their best interest.”
critical“The service had applied for Deprivation of Liberty Safeguards (DoLS) with the local authority but had not pursued an application to the court of protection. DoLS is not applicable to people living in their own homes.”
medication management
1 finding
moderate“Topical medicines, such as creams or lotions did not always have a date of opening on them. This meant that there was a risk of people receiving topical medicines which had expired.”
end of life care
1 finding
moderate
“The service did not always have end of life care plans, we saw one person with a life limiting health condition did not have an end of life support plan in place.”
governance
1 finding
moderate“These systems had not identified the areas of concern we identified regarding end of life care, medicines storage and the mental capacity act.”