moderate“risk assessments were not always sufficiently detailed to support staff how best to reduce risks”
incident learning
1 finding
moderate“a falls risk assessment not being updated following a fall or actions not being noted down to help stop incidents from reoccurring”
safeguarding
1 finding
moderate“not all staff we spoke to knew who to report concerns to outside of the organisation, for example to the local authority safeguarding team or the CQC”
consent capacity
1 finding
moderate
“one consent to care form was not signed by a person who had the mental capacity to make this decision because they were physically unable sign at the time”
staff training
1 finding
moderate“staff received training in the MCA and had their knowledge checked regularly. However, staff found it difficult to explain how this impacted on their job role on a day to day basis”
governance
1 finding
moderate“Audits were not effective in identifying where improvements could be made in all these cases”
person centred care
1 finding
minor“It was not clear in people's care plans when reviews took place or whether people and relatives were involved in discussions about their care”