critical“The provider was not always working within the principles of the MCA. For some people, where they may not have capacity to make a decision...there was not always assessments of their capacity”
governance
1 finding
critical“The provider's failure to implement effective quality assurance systems and processes to monitor and improve the safety and quality of the service.”
medication management
1 finding
critical“A person prescribed a medication, lacked guidance in place to ensure best practice was being followed. This resulted in the person not having their medication for pain relief for 24 hours.”
care planning
1 finding
moderate“Risk assessment relating to specific risks were not always in place. For example, a person who was assessed as being at risk of pressure sores and a person who was at known risk of choking”
record keeping
1 finding
critical“Failure to maintain securely an accurate, complete and contemporaneous record in respect of each service user was a breach of Regulation 17.”
staff training
1 finding
moderate“Recruitment checks were not always fully completed as some staff did not have the appropriate checks before being employed in the service.”