critical“Effective monitoring systems did not comprehensively monitor and improve the quality and safety of the service.”
moderate“The provider and registered manager had systems to monitor the quality of people's care however these were not always fully embedded.”
care planning
1 finding
critical“People's care plans and risk assessments were not always reflective of their current health and well-being needs.”
record keeping
1 finding
critical“Accurate records had not been maintained for each person and persons employed to carry out the regulated activity.”
medication management
1 finding
moderate“Staff would benefit from further guidance around the management and preferred administration of people's medicines and creams.”
missed or late visits
1 finding
moderate“Feedback from some people (and some relatives) and from reviewing the provider's systems indicated that staff were not always punctual.”
incident learning
1 finding
moderate“It was not comprehensively clear from the provider's systems whether they had taken action, analysed the incidents for any trends.”
supervision appraisal
1 finding
minor“Some records to be repetitive in parts and did not always explicitly describe the skills and support of each staff member.”
communication with families
1 finding
moderate“some relatives told us their views had not been sought. One relative had raised some concerns about the service to the local authority, as was not sure who to contact”
leadership
1 finding
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”