critical“When a person had been identified as living with a medical condition the provider had not developed a risk management plan providing guidance for care workers.”
incident learning
1 finding
critical“The provider had not consistently identified any lessons learned from these or preventative measures which were taken to reduce the risk of reoccurrence.”
governance
1 finding
critical“Sections covering care plans checks, safeguarding, incidents and accidents, complaints and compliments and late or missed visits had not been completed.”
safeguarding
1 finding
critical“Two of the records did not include any investigations into the cause of the incidents and any lessons which could be learned to reduce the risk of reoccurrence had not been identified.”
consent capacity
1 finding
moderate“The mental capacity assessment for another person indicated that they were not able to make decisions about their care, but the assessments which were completed were generic.”
complaints handling
1 finding
moderate“The provider did not always identify when actions were completed and preventative measures to reduce the risk of a similar concern occurring again.”
record keeping
1 finding
moderate“The providers medicines audit did not provide information to ensure the MAR charts were completed accurately and people's medicines were administered as prescribed.”
person centred care
1 finding
minor“Care plans did not always identify a person's preferences for food and drink, but care workers were advised to ensure each person was given a choice.”
end of life care
1 finding
minor“Care plans we reviewed did not include any information on the person's end of life care wishes.”