critical“Care plans and risk assessments did not contain enough guidance for staff to mitigate risks and provide safe support to people.”
minor“We found the risk assessment document for recording risks did not include all risks to people as these were sometimes recorded on the persons care plan instead.”
governance
2 findings
critical“Governance systems had not been fully implemented. A quality audit carried out by the service identified audits needed updating.”
minor“the providers records did not always reflect when these were due. For example one persons care plan was last reviewed in June 2019. The service had a policy of monthly care plan reviews.”
medication management
1 finding
critical“We could not be assured people were receiving medicines safely as there were no reviews or audits of medication administration records (MARS) available.”
missed or late visits
1 finding
moderate“The registered manager had no system in place to monitor late or missed calls and relied on people or their relatives being able to ring them.”
record keeping
1 finding
moderate“Actions from staff meeting minutes were not recorded so there was no evidence issues raised had been addressed.”
staff competency
1 finding
moderate“We did not see any evidence of competency assessments and noted five staff were waiting to have medicines training.”
person centred care
1 finding
moderate“Care plans we reviewed consisted of a list of tasks for staff to complete rather than detailing how people could be supported to have their needs met safely.”
other
1 finding
minor“A full employment history had not been obtained in 1 and only 1 reference had been obtained.”
end of life care
1 finding
minor“Peoples care plans did not contain evidence that the service explored people's preferences and choices in relation to end of life care.”