moderate“a person had 'Type 2 Diabetes'. There was no other information available for staff to follow when supporting this person”
critical“risk assessments carried out by the service did not always provide details on the actual risks to people”
minor“one person said, 'I have had carers coming for 3 years now, they are absolutely wonderful but I don't have a care plan.'”
staff competency
2 findings
moderate“Two out of three staff we talked to had a very limited knowledge about the Mental Capacity Act 2005 (MCA)”
minor
“A relative said, 'occasionally some carers are not up to standard, some don't seem to understand dementia clients and building a relationship.'”
complaints handling
1 finding
minor“informal concerns people made were not recorded...no record of action the provider told us they had taken in response to people who had raised concerns about staff time keeping”
end of life care
1 finding
minor“Staff had not received any end of life care training, although the managing director showed us recorded evidence that confirmed dates had already been arranged for all staff”
record keeping
1 finding
critical“people's medicine administration records (MAR) were not always signed for when either staff or relatives had administered medicines to people”
governance
1 finding
critical“Quality assurance audits were not carried out to identify, review and make improvements required to ensure people's safety”
staff training
1 finding
critical“some staff had not had a refresher training in safeguarding, medicines management and infection control since 2012”
missed or late visits
1 finding
moderate“We never know what time", "I do have concerns as [staff] do not arrive on time and [the relative] is left waiting for most of the morning”
supervision appraisal
1 finding
moderate“staff had not received regular one-to-one support through supervision and appraisal meetings”
consent capacity
1 finding
moderate“mental capacity assessment completed by the service which lacked information on how it was decided that the person had lacked capacity”
medication management
1 finding
moderate“One of the MAR sheets had a number of instances when the medicines were not signed for”
person centred care
1 finding
moderate“one person said, 'I have cancelled some care completely as over an hour & a half late and sometimes no one has turned up.'”
communication with families
1 finding
minor“One relative said, 'I do ring the office with my concerns but feel they are keen to get me off the phone.'”