critical“Medicines were not always documented and recorded diligently. For example, we found gaps in a number of medicines administration records (MARs)”
moderate“there were no care plans or 'protocols' in place to inform staff when to administer these [PRN] medicines, or what their intended affect was”
care planning
2 findings
critical“not all risk assessments provided staff with clear and concise information in how to manage and minimise the risk identified in the assessment”
moderate“The safety of staff was not assessed for every home visit they might attend. There were not always environmental or lone working risk assessments for some properties”
infection control
1 finding
minor“the registered manager told us that they would discuss COVID-19 risks with staff from the Black, Asian and Minority Ethnic (BAME) community. However, this was currently done informally.”
governance
1 finding
critical“The current quality assurance systems did not highlight the shortfalls we found in relation to people's care plans, risk assessments, medicines management, MAR charts and assessments of needs.”
missed or late visits
1 finding
moderate“Most complaints related to staff being late... Some people told us they were not always informed if staff were late.”
person centred care
1 finding
moderate“The electronic system focussed on a list of daily tasks the person required support with rather than how they would like to be supported.”
consent capacity
1 finding
moderate“we found that some relatives made decisions on people's behalf without having obtained the appropriate permission”
communication with families
1 finding
minor“While most people told us that they were informed if staff would be late, this was however not the case for everyone.”