moderate“People did not always have completed risk assessments following a review of people's care needs. For example, where people were at risk of skin breakdown or had experienced a seizure.”
missed or late visits
1 finding
moderate“Call records confirmed that staff could be in excess of an hour late and arrived earlier than the agreed times.”
governance
1 finding
critical“The lack of effective monitoring and oversight of the service was a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.”
incident learning
1 finding
moderate“Analysis of themes, trends or patterns were not assessed. Staff were not always informed of the outcome from these incidents to enable them to reflect on their practise.”
record keeping
1 finding
moderate“Care plans and risk assessments required further information to ensure these were complete...oversight and monitoring systems had not identified a lack of risk assessment or care plan.”
infection control
1 finding
minor“People told us that staff did not always wear their masks when providing personal care to people which was their preference and they needed to remind staff.”
supervision appraisal
1 finding
moderate“Staff meetings did not discuss staff views, suggestions or ideas, or review accidents or incidents, complaints, or share feedback from quality audits.”
communication with families
1 finding
minor“Changes within the staffing structure meant people and relatives found communication from the office was variable.”