critical“Medication administration records (MAR) were intermittently signed...Charts did not always have the full name, date of birth and allergies recorded.”
missed or late visits
1 finding
critical“One person who received a 45-minute daily morning call received only 15 minutes care on each visit over three mornings.”
care planning
1 finding
critical“Care plans in the community did not fully give guidance to staff to effectively support people and did not highlight important information.”
consent capacity
1 finding
critical“The registered manager told us that no one being supported by the service had undergone a capacity assessment by Creative Support.”
record keeping
1 finding
critical“A person...did not have documented there was a percutaneous endoscopic gastrostomy (PEG) in situ...same person was described as 'Nil by mouth'. This was not recorded.”
governance
1 finding
critical“Audits of medicines were completed monthly but did not identify errors on the MAR such as people's names and allergies not being recorded.”
staffing levels
1 finding
moderate“The inconsistency of regular staffing to support people was a common theme...people did not always receive a core group of staff members.”
supervision appraisal
1 finding
moderate“Staff told us they received supervision and appraisal, but we found the records lacked content and many of the sections were blank.”
person centred care
1 finding
moderate“One-page profiles for people in the community were not personalised and held limited information.”
cultural competency
1 finding
minor“Religious or cultural needs were not always recorded in peoples care plans.”
safeguarding
1 finding
critical“One staff member had received a disclosure and barring service check (DBS) three weeks after their start date...no evidence the staff member had shadowed more experienced staff.”