moderate“Information in people's care plans was task-focused and lacked person specific instructions about how they wanted their care to be delivered.”
governance
1 finding
moderate“The service's checks and audits had failed to identify the issues found with regards to risk assessments.”
incident learning
1 finding
minor“The template did not include a section for recording details about the immediate actions taken, the outcome and any follow up actions and lessons to be learnt.”
record keeping
1 finding
critical“Risks to people were not always assessed effectively and this meant people were at risk of receiving unsafe care and treatment. This is a breach of Regulation 12.”
end of life care
1 finding
minor“Care plans did not evidence a discussion surrounding end of life wishes had been considered.”