moderate“These systems need to be embedded within the service and staff to receive on-going training and support to ensure continued effective outcomes.”
critical“Quality monitoring systems were not effective to ensure people received safe care. Breach of Regulation 17 of the Health and Social Care Act 2008.”
care planning
2 findings
minor“End of life care...staff confirmed this was not always discussed and people's care plans did not record people's wishes or views.”
critical“Care plans and risk assessments were not always completed before people started using the service and they had limited information about how people needed to be supported safely.”
end of life care
1 finding
moderate“Information relating to people's care during this stage of life had not always been explored...people's care plans did not record people's wishes or views.”
staff training
1 finding
minor“The provider was offering care and support for people when they were discharged from hospital and some staff had not received the training to support people with reablement.”
medication management
1 finding
critical“Systems were not always in place to ensure people had their medicines when needed. People's care records did not include all the information about what medicines people had prescribed.”
safeguarding
1 finding
critical“When their concerns had been reported to the office staff, this information was not reported to the safeguarding team. Breach of Regulation 13.”
missed or late visits
1 finding
critical“One person needed support with their meals and had diabetes. It had not been identified that the call had been missed until the following day.”
incident learning
1 finding
moderate“There was no formal analysis to help identify any themes or trends and people's care was not always reviewed to reflect any significant events.”
consent capacity
1 finding
critical“Where people no longer had capacity to make decisions, assessments of capacity had not been completed and decisions were being made by family members without considering best interests.”
record keeping
1 finding
moderate“Care plans in the home were not always the most recent documents. Where changes were made in the care records, these were often posted to people with no checks to ensure receipt.”
person centred care
1 finding
moderate“Some morning calls were around lunch time and people told us that they felt uncomfortable staying in their night clothes all morning. Breach of Regulation 9.”
communication with families
1 finding
moderate“Where people had a hearing impairment and used sign language, there was no information available to support them to communicate and express themselves.”