minor“Records did not always show how and when people's mental capacity had been assessed.”
consent capacity
1 finding
minor“We recommend the provider develops more detailed records in relation to mental capacity assessments and best interest decisions.”
care planning
1 finding
critical“the documentation was not robust enough to ensure all known or potential hazards were assessed and plans put in place to reduce the likelihood of harm to a person”
governance
1 finding
critical
“the provider's systems around risk management had not been robust enough and did not include thorough risk assessment when a person went on holiday”
incident learning
1 finding
moderate“The provider had not recognised this and this had placed people at risk of harm. Once alerted to this the provider had responded and implemented a new system”