critical“Medicines were not always safely managed. Medicine risk assessments and risk management plans were not always in place.”
care planning
1 finding
critical“Risks to people were not always identified and risk management plans or guidance for staff was not always in place in relation to choking, falls, medicines and moving and handling.”
missed or late visits
1 finding
moderate“The staff have been late frequently. I've been contacting the senior staff at the office and they just apologise, but nothing really changes.”
staffing levels
1 finding
critical“Both staff don't usually turn up at the same time, one is always late. So, my [relative] is moved by only one staff member which is not safe.”
governance
1 finding
critical“The provider's governance of the service was not effective or robust. There was a lack of oversight, leadership and governance at the service.”
leadership
1 finding
moderate“The provider was not aware of the majority of the concerns we raised during the inspection.”
person centred care
1 finding
critical“People or their relatives were not involved in planning their care and support. Care plans were not reviewed regularly and were not signed by people or their relatives.”
consent capacity
1 finding
moderate“People who had a lasting power of attorney did not have these details recorded in their care plans.”
record keeping
1 finding
moderate“People's care plans recorded contradictory information about their medicines... some people's care plans either did not list their current medicines or had a list of their medicines that was out of date.”
communication with families
1 finding
moderate“As a relative, sometimes I'm kept in the dark as far as the visiting times and the staff don't let me know when they are going to be late.”
staff competency
1 finding
critical“The provider did not have a robust recruitment process and staff were not always recruited in line with this. Appropriate checks were not completed.”
end of life care
1 finding
moderate“People who had a 'Do Not Attempt Resuscitation' form (DNAR) in place, did not have information in their care plans about where in their home this could be located.”