critical“Care plans were not in place when people started receiving support from the service. The provider was reliant on staff using the local authority assessments when delivering care”
critical“Sometimes we go in blind, we have to use our own initiative and common sense [to deliver care].”
medication management
2 findings
critical“One person did not have a prescribed medicine administered for 17 consecutive days as the medicine had ran out. There was no evidence that this had been reported”
moderate“MARs were not always complete, recording of prescribed creams was not done consistently, PRN records were not always available”
governance
2 findings
moderate“Governance systems did not always address immediate risks when identified through auditing processes.”
moderate“Some of the audits completed by the service did not contain clear information about the action taken when concerns were identified.”
record keeping
1 finding
moderate“Reviews of people's care were not recorded. The service updated care plans annually...however, the reviews undertaken and the conversations held...were not recorded.”
infection control
1 finding
minor“We received mixed feedback from people and their relatives about staff cleaning up after themselves and about staff wearing PPE during care visits.”
missed or late visits
1 finding
minor“We received mixed feedback from people and their relatives in relation to staff arriving on time for visits, being notified if staff were delayed”
staff competency
1 finding
minor“We received mixed feedback from people and their relatives about how skilled staff were to deliver care. People told us some staff were better in delivering care than others.”