critical“There have been times when the [staff] haven't turned up until 8pm to give my [family member] their evening meal. My [family member] says it's too late.”
care planning
1 finding
critical“Risk assessments did not show enough information about 'how' staff should support a person to ensure safety and personal preferences were not always considered.”
person centred care
1 finding
critical“People's preferences were not fully explored meaning care was not person-centred. Concerns were not always responded to with a view to improving care.”
governance
1 finding
critical“Systems were ineffective for assessing and monitoring the quality of care, safety and personal needs of people using the service.”
record keeping
1 finding
moderate“gaps in staff members employment history had not been explored and recorded. This meant the provider could not be assured of the staff members good character”
complaints handling
1 finding
moderate“less serious complaints were not being recorded here. This meant it was difficult for the registered manager to analyse complaints for trends.”
staffing levels
1 finding
moderate“The rota was not planned in ways that meant care visit times were carried out at times people expected them. This resulted in people believing staff to be late”
end of life care
1 finding
moderate“the concept of serious illness, death and dying had not been approached with people or recorded in order for staff to be aware of their wishes”
medication management
1 finding
minor“care plans were not always clear as to who was responsible for the management and ordering of people's medicines.”
leadership
1 finding
moderate“there were gaps in the registered managers knowledge in relation to current best practice and statutory guidance”