moderate“care log audits identified records were not detailed enough to show clearly what care and support people received, but this was noted over three consecutive audits without any evidence of action”
minor“Two complaints did not have a date recorded, so we were unable to check whether the provider responded within an appropriate timescale.”
minor“We noted in two of the daily records the information was too brief and did not give a full picture of how the person had responded to the care provided”
minor“We shared with the provider the importance of compliance checks and audits in other areas such as staff files.”
care planning
2 findings
moderate
“some risk assessments lacked the personalised detail needed to fully inform staff how to care safely for them”
moderate“Some care plans contained documentation that was duplicated or out of date, and it was not always immediately clear which copy was currently in use.”
medication management
2 findings
critical“Some medicines records were not complete, meaning we could not be fully assured people received their medicines as prescribed. Two of the records we looked at contained unexplained gaps.”
moderate“People's care records did not contain specific instructions about what PRN medicines were prescribed for and under what circumstances they should be administered.”
governance
2 findings
critical“Systems for driving service improvement were not always effective...they did not always lead to those improvements being made.”
moderate“The provider's audits had failed to identify the concerns we found around a lack of evidence that people consented to their care, risk management, medicines management.”
infection control
1 finding
moderate“Two members of staff at the office were not wearing face coverings in line with current COVID-19 guidance during our inspection.”
incident learning
1 finding
minor“one person had two recent falls recorded on incident forms but their name did not appear on the matrix, meaning the system may not always have been used effectively.”
consent capacity
1 finding
critical“Care plans contained consent forms, but the ones we looked at were signed by people's relatives, by the manager of the service or not at all.”
complaints handling
1 finding
minor“One complaint did not have any information about what the provider had done in response.”
staffing levels
1 finding
moderate“Recruitment systems were not fully robust at the agency. Of the six staff records we examined two of these did not contain previous employment references.”