critical“Medicines administration charts showed gaps in medication, did not always demonstrate complete courses of medications had been given and amendments were not always signed and dated.”
governance
1 finding
critical“An effective system was not in place to monitor and manage the quality and safety of the service and ensure regulatory requirements were met.”
safeguarding
1 finding
critical“The provider did not have an effective system to record and investigate safeguarding issues.”
incident learning
1 finding
critical“Systems to monitor accidents and incidents were not effective and did not promote learning. Incidents were not always recorded.”
record keeping
1 finding
critical“Management audits had not taken place and the provider did not have a robust system to identify errors and omissions in records.”
staff competency
1 finding
moderate“An effective system was not fully in place to demonstrate all staff were competent to administer medication and monitor completion of other training.”
staff training
1 finding
moderate“Quality assurance processes did not always record whether some staff were competent to administer medication and other training they had undertaken.”
supervision appraisal
1 finding
moderate“Staff were receiving supervision on a regular basis. However, staff did not receive an appraisal in line with the provider's appraisal policy.”
care planning
1 finding
moderate“Care plans were not completed in a way which promoted person centred care. The provider did not ensure care plans included enough information about people's needs.”
missed or late visits
1 finding
moderate“One told us, 'There's been a couple of times when nobody has turned up, because she was accidentally missed off the rota.'”
consent capacity
1 finding
moderate“Information about people's consent to care and how this was gained was not fully recorded. Records did not always evidence a relative's legal status.”
person centred care
1 finding
moderate“People and their family members were not consistently involved in their care planning. Some people's care had not been reviewed for over 18 months.”
staffing levels
1 finding
critical“References, qualifications and employment histories were not always requested by the provider prior to applicants starting work.”