critical“Systems were either not in place or robust enough to demonstrate effective oversight and management of the service. This could place people at risk of harm.”
consent capacity
1 finding
critical“Mental capacity assessments completed were not decision specific... records still did not cover some aspects required in a mental capacity assessment and best interest decision record.”
record keeping
1 finding
moderate“provider was not always following their own medicine policy and good practice guidelines in relation to recording the support provided to people who needed to be reminded or prompted”
staff training
1 finding
moderate“staff had started working independently before receiving all required training, this included practical moving and handling training.”
staffing levels
1 finding
moderate“staff had started working before DBS checks had been completed.”
incident learning
1 finding
moderate“medication audits were completed but these had not identified the issues with recording of medication found during this inspection.”