moderate“The governance systems in place were not robust. Minimal audits had been carried out which meant the provider did not always identify areas for improvement.”
medication management
1 finding
moderate“protocols were not in place to guide staff when to administer 'as and when required' medicines.”
staff competency
1 finding
minor“Competency assessments were carried out by the management team but not recorded.”
care planning
1 finding
moderate
“some areas of the care plans required more person-centred information. For example, to contain, people's like, dislikes and how they wish to receive their support.”
record keeping
1 finding
moderate“Risk to people were assessed to ensure measures were put in place to mitigate these risks. Some risk assessments required further detail to ensure records were robust.”
infection control
1 finding
moderate“Individual COVID-19 risk assessments were not in place for people and staff. The provider addressed this during the inspection.”
missed or late visits
1 finding
minor“Occasionally timing can be off, for example two hours early”
end of life care
1 finding
minor“Records did not always show people had been given the opportunity to discuss their end of life wishes.”
person centred care
1 finding
moderate“Some work was required to ensure the service delivered a fully person-centred service.”
communication with families
1 finding
minor“another professional told us the management team was sometimes difficult to contact and work was required to improve working relationships”
supervision appraisal
1 finding
minor“The majority of staff had only worked at the service a short period of time so had not yet had their supervisions.”