minor“Some risk assessments lacked some detail about how to mitigate risks. For example, one person was at risk of malnutrition. The risk assessment gave minimal guidance.”
critical“risks that had not been fully assessed and some risk assessments had not been completed correctly to show how these risks could be reduced”
consent capacity
2 findings
moderate“Where people lacked capacity to consent to their care the provider had not followed the principles of the Mental Capacity Act (MCA) 2005.”
moderate“staff had not received training in MCA therefore we could not be assured that staff fully understood the principles in relation to the Act”
record keeping
2 findings
minor“The provider had a mental capacity assessment template with the MCA policy however they were not using this template.”
minor“daily records and care plans needed to be more person centred in respect of people's individual preferences and what support they received”
staff training
1 finding
minor“We noted first aid training had not been offered for the period of 2016 to 2017.”
medication management
1 finding
critical“staff were not always completing the medicine administration records (MAR's) correctly as there were a number of gaps where staff had failed to sign the MAR”
staff competency
1 finding
moderate“regular medicines competency checks had not been completed to ensure that staff were safely supporting people with their medicines”
supervision appraisal
1 finding
minor“frequency of this varied from once to twice a year...in one staff file we found their appraisal had not been completed”
governance
1 finding
moderate“although some of the areas we checked had been identified through the provider's audit processes, these did not pick up the concerns relating to risks and medicines”