critical“we looked through ten people's MAR charts and audits for the last 12 months and found unexplained gaps in three people's MAR charts that had not been picked up in the MAR audits”
care planning
1 finding
critical“At the time of the inspection we did not find risk assessments or risk management plans that were specific to people's health conditions.”
governance
1 finding
critical“Quality assurance systems and processes were not sufficiently robust.”
record keeping
1 finding
moderate“information was not readily available, and records were not always presented promptly during our inspection”
incident learning
1 finding
moderate“accident and incident reporting was inconsistent. Reports did not always contain follow up actions nor were they signed off by a manager.”
missed or late visits
1 finding
moderate“People told us staff seemed rushed and did not always arrive on time. One person said, 'I think the carers seem rushed at times.'”
consent capacity
1 finding
moderate“care plans contained no information about people's mental capacity other than stating whether they had a diagnosis of a health condition where capacity might fluctuate”
person centred care
1 finding
minor“There were mixed views on the service's promotion of independence.”
communication with families
1 finding
moderate“people's service user agreements and their care plan reviews were often unsigned or if they were signed the service did not maintain a copy at their registered address”