critical“People did not always have assessments carried out when needs were identified. The lack of assessments placed people at risk of avoidable harm.”
medication management
1 finding
critical“medicines administration records (MAR) were not always accurately completed...we could not be assured that people now received medicines as prescribed.”
consent capacity
1 finding
critical“Where people may have lacked capacity to make decisions about their care, the registered manager had not assessed capacity in accordance with the MCA 2005.”
staff training
1 finding
critical“staff had completed in excess of 20 modules in one day...Staff spoken with could not all demonstrate their knowledge to us around areas such as mental capacity and safeguarding.”
governance
1 finding
critical“Quality monitoring systems and policies were in place but were not effectively operated to drive continuous improvement in the service.”
safeguarding
1 finding
critical“there was a significant delay from when they suspected the person was at risk of harm to reporting.”
supervision appraisal
1 finding
moderate“supervision was not a structured meeting to review performance, discuss development and review objectives.”
person centred care
1 finding
moderate“Care plans lacked detail describing how personalised care and support plan based on what matters to people, their preferred outcomes and how they will be achieved.”
incident learning
1 finding
moderate“Staff entered incidents into the daily log, and not a separate report, meaning these were at times delayed in being picked up.”
missed or late visits
1 finding
minor“Time keeping varies, sometimes too early or late. No one lets us know they are late.”
communication with families
1 finding
minor“I was complaining that they hadn't told me they had contacted my GP on my behalf. I felt a fool when the surgery rang me, and I didn't know.”
record keeping
1 finding
critical“Records were not completed accurately or well maintained...Medicine records were not updated which meant the provider could not be assured people received their medicines.”
staff competency
1 finding
critical“Staff had completed online medicines awareness training and administered medicines without the required higher-level administration, management of medicines and competency assessment.”