critical“More than half of the risk management plans we reviewed lacked information to help staff provide safe care.”
moderate“The majority of people's care plans we looked at did not contain enough information.”
governance
1 finding
critical“Auditing systems were not always operated effectively. Completed checks had not identified some care records and risk management plans lacked information.”
record keeping
1 finding
critical“Accurate and complete records in respect of each person were not maintained.”
consent capacity
1 finding
moderate“Decision specific mental capacity assessments had not always been fully completed during care planning to determine whether or not people had capacity”
safeguarding
1 finding
critical“We had not been notified about two allegations of abuse that had occurred during March and July 2022.”
incident learning
1 finding
moderate“incidents were not always analysed to identify triggers or patterns to prevent recurrence.”
communication with families
1 finding
moderate“three out of five people spoken with explained they had difficulty communicating with staff who supported them for whom English was a second language.”
medication management
1 finding
minor“a fifth person explained staff had forgot to apply their prescribed cream to their skin that morning.”
leadership
1 finding
moderate“Managerial oversight of the service needed to be strengthened and improved.”