moderate“Risks to people's health were not always safely managed... these risks had not been assessed by the provider. These risks included for example choking and skin integrity risks.”
moderate“A paper care plan had incorrect information relating to levels of food to administer, the amount recorded was much higher than the level recommended by the health professional.”
moderate“for both new business that had been referred to the service by health professionals and other new care packages no assessment had been completed.”
governance
2 findings
critical“the provider had not operated an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.”
critical
“This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
medication management
1 finding
moderate“Risks associated with people's medicines had not always been assessed... it was unclear what actions were taken as a result of spot checks when issues were found.”
staff competency
1 finding
moderate“staff competency checks were not taking place in relation to PEG care.”
other
1 finding
moderate“the provider had not obtained a full employment history for either of these new staff. This is an important check to ensure staff are safe to work in health and social care.”
consent capacity
1 finding
moderate“staff we spoke with had varying levels of understanding of the MCA principles... the provider had not assured us there was a system in place for checking staff competencies around the MCA.”
person centred care
1 finding
minor“information relating to people's likes and dislikes was very limited, and there was no information relating to people's life history.”
record keeping
1 finding
minor“Policies and procedures at the service were generic. The complaints and compliments policy were not dated, neither was the IPC policy.”