critical“People had experienced missed and late care calls.”
governance
1 finding
critical“The registered manager did not have an effective care call monitoring system and people had experienced missed and late calls.”
staff training
1 finding
moderate“Staff are kind, but they are 'green' and not knowing what to do, they need more training.”
staff competency
1 finding
moderate
“spot checks had taken place, these had not always assessed staff's skills and competencies to ensure learning had taken place from the training given.”
record keeping
1 finding
moderate“improvement was needed to the records maintained such as to include dates and full detail about the incident and investigation.”
medication management
1 finding
moderate“Staff did not currently have information available to them about a person's medication to refer to in the event of an emergency.”
care planning
1 finding
moderate“one care plan reviewed had contradictory information which in one section stated a person was at low risk of dehydration and in another section recorded they were at moderate risk”
consent capacity
1 finding
moderate“Improvement was needed to include mental capacity assessment information in people's care plans.”
communication with families
1 finding
minor“Due to some staff's accent, some people and relatives could not always understand what was being said to them.”
leadership
1 finding
moderate“the service was not consistently well managed and well-led. Leaders and the culture they created did not always promote high-quality, person-centred care.”
other
1 finding
moderate“One staff file had gaps in employment and education history, and these gaps had not been explored by the registered manager at interview stage.”