critical“Not all care plans had guidance and strategies for staff on how to identify and manage health risks, such as type 2 diabetes and epilepsy.”
medication management
1 finding
critical“The provider had not completed any recent medicine audits, or competency checks on staff. One person's medicine administration recording sheet did not identify they were allergic to one medicine.”
governance
1 finding
critical“Not all quality assurance activities were consistently completed or effective. They had not identified the shortfalls we found during our inspection.”
missed or late visits
1 finding
moderate“The teatime visit is often very late, it should be 4 pm but has been 6-6.30pm.”
record keeping
1 finding
critical“Accurate and contemporaneous records related to each service user, persons employed, and the management of the service had not been kept.”
leadership
1 finding
moderate“The service did not have a manager registered with the Care Quality Commission as required by law at the time of our inspection.”
staff competency
1 finding
moderate“Three staff we spoke with could not explain what one of the conditions were, or how these conditions impacted on the person's life.”
end of life care
1 finding
minor“Care plans did not identify if people had a DNACPR in place and where it was stored. The provider did not discuss preferred places of care or advanced care planning.”
infection control
1 finding
moderate“We were not assured that the provider was using PPE effectively and safely as we received conflicting information.”
complaints handling
1 finding
moderate“We asked about additional complaints we were aware of. The regional manager said these were stored in personnel files and would submit them. These were never received.”
person centred care
1 finding
moderate“One person said, 'I haven't seen a care plan I think they learn what my needs are by word of mouth to be honest.'”