critical“Risk assessments and risk management plans lacked detail and did not always provide the required information to ensure that people who used the service were protected from risks.”
critical“Where a suction machine was needed because of a debilitating condition there was no appropriate risk assessment.”
critical“The risk assessment of a person with diabetes was not sufficiently detailed and did not include guidance for responding to symptoms of high or low blood sugar levels.”
governance
2 findings
critical“The provider's care records checks were not effective because they had not identified that risk assessments and care plans were not being completed appropriately.”
critical
“No audits had been done regarding complaints, incidents, and risk assessments. Although the service had started to check the punctuality of visits and any missed visits, these checks and audits were not documented.”
record keeping
2 findings
moderate“People's care plans lacked people's background...Details of how tasks should be provided were not personalised and this information was not available for staff reference.”
minor“The assessment of people's skin condition had not been completed. As the form was not completed, we could not be sure if the assessments were missed or not.”
missed or late visits
2 findings
critical“Out of the five records examined, all had at least ten occasions when staff did not arrive on time and stay the agreed duration.”
critical“In one recent incident, staff did not visit a person for several days and management was unaware of this until they were informed by a care professional.”
person centred care
1 finding
critical“Care plans were not always personalised and provided care workers with the necessary information to provide person centred care to people who used the service. This was a breach Regulation 9.”
safeguarding
1 finding
moderate“We found that in one DBS check that the member of staff had a previous criminal conviction. However, the service did not undertake a risk assessment to ascertain if the person was safe.”
consent capacity
1 finding
moderate“Most MCA assessments were mostly ticked...there was no detail to state how a mental capacity assessment was being undertaken.”
communication with families
1 finding
minor“How people communicated and understood information presented to them, was only recorded in some care plans. This meant that care workers did not always have information of how to communicate with people.”
complaints handling
1 finding
minor“In one complaint the service did not record what action had been taken by the provider to improve the service.”
medication management
1 finding
moderate“There had been a recent incident where a person had not been administered their medicines as prescribed. Medicine audits were done two monthly. This was not sufficient.”