moderate“The provider had not assessed the person's mental capacity or recorded they still considered the ongoing care plan was in the person's best interests.”
critical“Family members had signed on behalf of their relatives but there was no clear indication of why the person who used the service was unable to sign the care plan.”
care planning
2 findings
minor“Protected characteristics under the Equalities Act 2010 were identified and recorded in people's care plans...the quality of the information varied from detailed information to, '[Person] had no cultural or religious needs.'”
critical“There was a lack of individual risk assessments. One file indicated the person had particular needs which could be a potential risk to others...but there were no individual risk assessments.”
medication management
1 finding
minor“Medicines were generally managed safely but annual medicines competency testing was not in place.”
end of life care
1 finding
minor“The provider did not have any records of people's end of life wishes. This meant people's wishes and preferences for care at the end of their lives were not always known.”
missed or late visits
1 finding
minor“"The weekend one she has been an hour late", "Sometimes they might be a little late but nine out of ten times they're just right"”
complaints handling
1 finding
minor“some people did not always feel their concerns were adequately addressed”
safeguarding
1 finding
critical“The service did not inform the Care Quality Commission (CQC) of the safeguarding alert as they were required to do. This was a breach of Regulation 13.”
governance
1 finding
critical“The provider did not always record outcomes or analyse service information such as complaints or feedback from surveys. This was a breach of Regulation 17.”
incident learning
1 finding
moderate“Incident and action taken were described but there was no record of the follow up or analysis of trends recorded to improve future service delivery.”
staff competency
1 finding
moderate“The MCA was not included in training, which meant staff, including the registered manager, did not have a good understanding of the MCA.”
record keeping
1 finding
moderate“Care records and staff files lacked audits to ensure files contained evidence that systems were being followed to improve service delivery and keep people safe.”
supervision appraisal
1 finding
minor“We saw evidence of supervision taking place but not four times a year as indicated by the service's supervision policy.”