critical“there was no medicine administration record (MAR) in place for staff to follow the prescriber's directions or to record administration as required.”
care planning
1 finding
critical“Care plans and general risk assessments failed to provide staff members with the information needed to ensure people received safe care which met their needs.”
staff training
1 finding
critical“Staff had not received all the training they needed. Whilst the care certificate is a part of training...it does not provide all the knowledge, skills and experience staff need.”
staffing levels
1 finding
moderate“There was no effective care call monitoring system in place...One person told us about frequent lateness they experienced, telling us, 'Staff are often late'.”
safeguarding
1 finding
critical“People were not always protected from risks of abuse because care staff were not issued with an identity badge before undertaking care calls alone to people.”
governance
1 finding
critical“The provider did not have effective quality assurance systems and processes in place.”
record keeping
1 finding
moderate“no record of the initial assessment was recorded or included in the plan of care.”
staff competency
1 finding
moderate“A staff member referred to 'calling 911' when they should have referred to 999 for a UK emergency number.”
infection control
1 finding
moderate“The provider had no information available for staff to refer to about infection control and prevention when working in people's own homes.”
leadership
1 finding
moderate“The provider had another full-time job elsewhere...This meant support available to staff was limited.”
incident learning
1 finding
minor“There was a system in place to record any accidents or incidents but there was no analysis process in place for when needed.”
person centred care
1 finding
minor“People's plans of care did not give staff information about their hobbies and interests.”