critical“The provider had not always identified and effectively investigated safeguarding concerns to people. This was a breach of regulation 13.”
governance
1 finding
critical“The service did not have robust processes to monitor the quality and safety of the service. This was a breach of Regulation 17 [Good governance].”
medication management
1 finding
moderate“We were not assured staff were competent in administering PRN medicines...one person had been administered PRN medicine at each of their visits.”
record keeping
1 finding
moderate“People's care records were not audited; this meant we were not assured all information was included.”
incident learning
1 finding
moderate“The entries were not detailed, and it was not always clear what had happened...incident reports in a paper file, but this was not available for us to review.”
care planning
1 finding
moderate“A person was being cared for in bed, but the care plan stated they were hoisted to the toilet at each visit...risk assessment did not include guidance for staff on hoisting.”
staff competency
1 finding
moderate“A member of staff we spoke with was not able to tell us what [safeguarding] is and another described it as, 'It is making sure they are not hurting themselves.'”
person centred care
1 finding
minor“Staff did not always promote people's independence. A relative told us, 'They do not encourage [person] at all, just keep telling them to sit down.'”
complaints handling
1 finding
moderate“We found a complaint had been reviewed and closed which should have been treated as a safeguarding concern.”
consent capacity
1 finding
minor“We found these [MCA assessments] were not personalised; the description of what they were able to do was identical on 2 people's forms.”