critical“comprehensive assessments and risk management plans of people's individual risks had not always been completed to direct staff in delivering safe care and support”
medication management
1 finding
critical“Risk management plans and protocols relating to people who were supported or prompted to self-medicate, receive time specific medicines, covert medicines or medicines to be used 'as required' were not detailed.”
governance
1 finding
critical“it was not clear how they had responded to individual alerts or if they had identified any patterns or trends and the action taken to address late visits, concerns or incidents.”
record keeping
1 finding
moderate“People's care records on the provider's electronic care management system were not always completed in detail to reflect their care and medicines requirements and assessments.”
consent capacity
1 finding
moderate“the assessment of people's mental capacity on the provider's electronic care management system was not in line with the principles of the MCA.”
infection control
1 finding
moderate“staff had not received regular COVID-19 testing in line with government guidance which meant staff may be transmitting the virus if they were asymptomatic.”
end of life care
1 finding
minor“the registered manager stated that they were reviewing their end of life systems, care planning and staff training to ensure that they could respond effectively and safely”
incident learning
1 finding
moderate“it was not clear from the electronic system that the alerts raised by staff had been reviewed and effectively managed by the managers in a timely manner.”