moderate“staff did not receive first aid training and the first aid policy related to staff in the workplace, not people using the service.”
record keeping
1 finding
moderate“They were not collated anywhere for analysis, and we identified 2 other incidents where appropriate action had been taken but not recorded.”
consent capacity
1 finding
moderate“People's mental capacity assessments did not state what the specific decision being assessed was.”
governance
1 finding
moderate
“monthly audits...did not always identify where a medicine had been logged as not administered or refused without explanation.”
incident learning
1 finding
minor“Staff were not able to give any examples of lessons learned.”
staff competency
1 finding
moderate“staff files and found they did not include full employment history and have appropriate references...no risk assessment completed regarding the lack of explanation of employment history gaps.”