moderate“the audits were not as comprehensive as they could be in cross checking staff were carrying out tasks as directed in the care plan, for example only a small percentage of the daily notes were checked”
moderate“Systems and checks needed to be completed and practice embedded into to assure the quality of service people received.”
record keeping
2 findings
minor“we saw in the daily notes written by a staff member the actions they had taken which were not in the care plan.”
moderate“When a best interest decision had been made by health professionals, records of this had not been retained within the care plan.”
leadership
1 finding
moderate“they did not have in place a support network or external scrutiny to help them look at their practice and offer guidance and professional expertise.”
person centred care
1 finding
moderate“language in the care plans and daily notes they used to describe people with a learning disability or autistic people was not always respectful. For example, "I am non-verbal, therefore I do not have the capacity."”
medication management
1 finding
moderate“Medicine policies and procedures needed to be updated to reflect current guidelines, in relation to covert medication. A person required PRN medication... Protocols needed to be put in place.”
infection control
1 finding
moderate“There was a lack of information or guidance for staff to understand how to protect themselves and others from the potential risk of infection.”
consent capacity
1 finding
moderate“One person lacked capacity to make decisions in relation to personal care. An assessment considering their decision-making ability had not been carried out.”
end of life care
1 finding
minor“Care plans did not explore people's preferences in relation to end of life care... staff had not received end of life care training.”
communication with families
1 finding
minor“The registered manager needed to complete training relating to the accessible communication standards. Easy read version of key policies was not available.”
incident learning
1 finding
moderate“Systems needed to be put in place, so learning could be cascaded if incidents, accidents, complaints or safeguarding events occur.”