moderate“One person could sometimes become agitated however there was no information about what may cause the person to become upset or what staff could do to try and calm the person down again.”
moderate“One person was supported to monitor their blood sugar levels for their diabetes. There was no guidance available in the care file about what a safe range the blood sugar reading should be.”
moderate“In two care plans it was not clear about whether one or two members of staff were needed to support people.”
moderate“The audits that had been completed had not identified that some care plans did not contain up to date information or did not detail the specific support that people required.”
governance
3 findings
moderate
“The medicines audits did not identify missing information regarding the medicine and poor recording about administration of medicine by some staff.”
moderate“Some care plans had not been audited for several months and therefore some omissions had not been identified.”
moderate“care plans and medicines administration record audits were completed but they did not clearly show which records had been reviewed as part of the audits.”
medication management
2 findings
critical“Some of the MAR charts that we checked had missing information such as the dosage, where a topical medicine should be applied and it wasn't clear if a medicine was PRN or a regular prescription.”
moderate“there were no specific plans in place to guide staff on when or where they needed to apply these creams...people could not be assured they were getting their creams as prescribed.”
record keeping
2 findings
critical“There were gaps in the recording in people's MAR charts and there were no explanations so we could not be sure that all people were consistently having their medicines as prescribed.”
minor“Recording can sometimes be an issue so we are working hard on that too.”
person centred care
2 findings
minor“The service also did not consistently collect or utilise information relating to people's sexuality...could not always be sure they were effectively supporting people with maintaining same-sex relationships.”
minor“we received a mixed response in relation to people receiving continuity of calls from the same member of staff”
consent capacity
2 findings
critical“The service did not always act in accordance with the Mental Capacity Act 2005 when people were unable to consent to their own care and treatment.”
critical“relatives had signed consent on behalf of people without the necessary legal powers to do so...they had not asked for the relevant documentation to evidence this.”
staff training
2 findings
moderate“some staff told us they could not remember anything about the MCA, some were not sure whether they had received training.”
minor“The manual handling training is done online and it should be face to face, that would be much better.”
missed or late visits
1 finding
minor“Some people, however, told us they were not always sure what time staff would arrive. We raised this with the registered manager who confirmed they would look into this.”
staffing levels
1 finding
moderate“Calls sometimes overlap but you can't get to them...It is definitely common to have overlapping calls, especially at weekends. I asked the care coordinator and they told me to cut my break short.”
communication with families
1 finding
minor“registered mangers were not always pro-active at returning calls when people or their relatives had contacted the office by telephone”