critical“Risks to people were not well managed. There was a lack of risk assessments specific to people's needs such as catheter, seizures and skin integrity.”
medication management
1 finding
critical“Medicines were not managed safely. The service was not always clear about its responsibilities and role in relation to medicines.”
staff training
1 finding
critical“Staff had not received accredited practical training for moving and handling, catheter care and percutaneous endoscopic gastrostomy (PEG) support when they were supporting people with these needs.”
supervision appraisal
1 finding
moderate“Some people have not had supervisions for over a year and they should be bi-monthly. Some appraisals haven't even happened.”
governance
1 finding
moderate“The provider did not have systems in place to identify trends across incidents and accidents or complaints.”
person centred care
1 finding
critical“People's needs, choices and preferences were not assessed or recorded accurately, timely or in a person-centred way.”
record keeping
1 finding
moderate“Care plans lacked details of people's preferences. Generic content in care plans was also duplicated across several people's care records.”
end of life care
1 finding
moderate“The service did not consistently engage people in planning their end of life care and did not always record individual wishes.”
communication with families
1 finding
minor“The provider did not always provide relatives with updates and feedback of the support provided. 'I don't get an update unless I ask a question.'”
complaints handling
1 finding
moderate“The complaints system did not allow the provider to identify trends and apply learning to practice within the service.”
leadership
1 finding
moderate“The manager lacked the support and infrastructure in the senior management team to manage a robust oversight of the service and to focus on improvements.”
staff competency
1 finding
critical“Senior staff had provided this training despite not being accredited to do so.”
cultural competency
1 finding
minor“The provider had not been ensuring new staff were supported to adapt to a new culture and new role. 'They are naturally slightly disadvantaged.'”
consent capacity
1 finding
moderate“There were not always mental capacity assessments in place for significant decisions where there was reason to believe a person may lack capacity.”