critical“we could not be assured people had received all their medicines as prescribed. For example, we found gaps on MAR, no one was able to confirm if people had received these medicines.”
care planning
1 finding
critical“When people had individual risks such as epilepsy, sore skin or a health condition there was not always care plans or risk assessment in place identifying this.”
staff training
1 finding
critical“When people had individual needs or health conditions, staff had not always received training. This included epilepsy, oxygen therapy, colostomy care and management of skin.”
governance
1 finding
critical“Audits in place were insufficient to check the quality of the service. A medicines audit was being completed monthly it had not identified any of the concerns we found with medicines.”
person centred care
1 finding
critical“People did not always receive consistent care in line with their preferences. This placed people at risk of harm. This was a breach of regulation 9.”
missed or late visits
1 finding
moderate“Sometimes they are late, and I am left waiting...in July of this year the carers didn't turn up for the last two calls one day, we were told someone would get back to us they never did.”
complaints handling
1 finding
moderate“I phoned the office to complain about staff turning up late, there is always some excuse...I phoned again and they tried to blame me.”
record keeping
1 finding
moderate“There were no individual plans in place for people stating how they may choose to communicate and the level of support they may need with this.”
staffing levels
1 finding
moderate“The provider acknowledged over the previous few months there had been some concerns with staffing...records showed people received calls, however these were sometimes later than planned.”
supervision appraisal
1 finding
moderate“There were no systems in place to ensure staff had received adequate training to support people.”
end of life care
1 finding
minor“There was no one currently using the service who was end of life care. There were no plans in place to consider this for people.”