moderate“one person recently had a social care review which noted their risk of choking had increased. Their care and risk support plan had not been updated to say what that meant for the care being delivered”
medication management
1 finding
moderate“There were no protocols in place to advise staff when people should be supported to receive those medicines. This meant people were at risk of being given medicine when they should not have been”
governance
1 finding
critical“There was little evidence of regular audits being undertaken...a lack of regular audits of daily notes, MARs and monitoring charts meant the provider was not checking that the care was delivered as planned”
incident learning
1 finding
moderate“one person recently had a guided fall in their home when carers were present, but this had not been recorded on an incident form”
consent capacity
1 finding
moderate“there was no specific MCA tool being used in the care file to assess decisions and provide guidance to staff”
supervision appraisal
1 finding
moderate“Staff competency checks, spot checks, supervision and appraisals were taking place but there were limited systems in place to ensure these were regular and any identified actions were followed up”
record keeping
1 finding
minor“record keeping needed to be strengthened to ensure that updates from other professionals, and what that meant for people's care, was reflected in the individual care files”