moderate“care plans were not developed from the assessment that identified people's care or support needs. For example, around supporting people with dementia or skin integrity.”
record keeping
1 finding
moderate“Incidents that were reported to the manager were not always documented. Themes and trends around the types of incident or injury were not assessed.”
incident learning
1 finding
moderate“Lessons learned were not formally embedded within the team culture...this was discussed between carers and not led by the registered manager.”
staff training
1 finding
moderate“key areas such as first aid, basic life support, person centred care and incident reporting had not been provided as required.”
governance
1 finding
moderate“The registered manager did not demonstrate a robust knowledge of regulatory requirements, risk analysis and quality assurance.”
safeguarding
1 finding
critical“Where staff had reported incidents such as bruising, skin integrity issues...we could not be assured these had been investigated and reported to CQC or the local authority.”
missed or late visits
1 finding
moderate“The provider did not have a system at the time in place which alerted them to calls which were late or missed.”
person centred care
1 finding
minor“Although care plans were not recorded in a person-centred way, people and relatives said their care was personalised.”