critical“we found some concerns which had not been reported. An example included a serious medicines error which involved a team of staff.”
missed or late visits
1 finding
critical“the service had failed to identify when people's visits had been missed...One person's visit was missed in September 2019 due to the over sight of the visit by the member of staff.”
governance
1 finding
critical“The lack of quality assurance systems that identified monitored and mitigated risks were a breach of Regulation 17 Health and Social Care Act 2008.”
record keeping
1 finding
moderate“People's care records were not always up to date to reflect the changes of people's needs...one person's support plan stated they self-medicated. However...staff administered the person's medicines.”
care planning
1 finding
moderate“one person who the service supported lived with dementia. The person's support plan did not reflect upon how the person's dementia had impacted them.”