critical“People's care plans did not clearly identify people's specific needs and how they were met. There was limited information provided to staff in how to provide the care and support required.”
critical“A person's care plan referred to them as the name of another person using the service... a male was referred to as he, she, him and her.”
record keeping
2 findings
moderate“Records were contradictory in parts, did not always identify how risks were mitigated and did not provide enough detailed information to guide staff in how people's needs were to be met.”
moderate“A person's care records stated they did not have a DNACPR decision in place. However, on the person's 'grab sheet'... it stated there was a DNACPR in place.”
governance
2 findings
critical“An audit in people's care records completed in April 2022 rated them as 100% compliant. The audit had not picked up the shortfalls we had identified in care plans and risk assessments.”
critical“Systems were not robust to assess, monitor and mitigate risks to the health, safety and welfare of people using the service. This placed people at risk of harm.”
person centred care
2 findings
moderate“People's care plans were not always detailed enough to guide staff in how people's specific needs were to be met... not specific to identify what areas people required assistance with.”
critical“People's care records were not always person centred and did not always identify the person's individual needs. This placed people at risk of receiving inappropriate care.”
medication management
1 finding
critical“One person's records stated they did not need assistance with their medicines, however, they did state in another part that care workers were to prompt the person to take their medicines.”
staffing levels
1 finding
critical“27% of visits were less than half the planned time and 50% of visits were less than 70% of the planned time.”
missed or late visits
1 finding
critical“27% of visits had no travel time provided... staff did not always spend the assessed length of time with people, as planned.”
cultural competency
1 finding
moderate“We received concerns about all staff not understanding how to support people with the preparations of their meals... cultural training to staff.”
end of life care
1 finding
moderate“From the training records only 10 of 23 staff had completed specific end of life training.”
incident learning
1 finding
moderate“The action plans implemented following the audits did not identify the outcomes to the actions.”