critical“Governance systems did not identify or monitor the quality of care provided and there was lack of oversight from senior leaders.”
staff training
1 finding
critical“Not all staff had completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards; Loss and Bereavement; Palliative Care; Incident Reporting; or Lone working.”
medication management
1 finding
critical“Staff were supporting patients with administration of medicines, including eye drops and controlled drugs without any training or competency assessments.”
care planning
1 finding
critical“Care plans were in place for patients in the day care and palliative home care services. These were not person centred and did not include discussions about what was important to the patient”
consent capacity
1 finding
critical“Staff did not understand how and when to assess whether a patient had the capacity to make decisions about their care.”
incident learning
1 finding
moderate“Staff in the day care service had not received training in incident reporting. This meant that the service could not be assured staff had the training required appropriately identify and report incidents.”
safeguarding
1 finding
moderate“Staff had training on how to recognise abuse but did not know how to report it... staff we spoke with did not know how to make a referral themselves.”
supervision appraisal
1 finding
moderate“we could not be assured that managers supported staff to develop through yearly, constructive appraisals of their work or provided regular ongoing supervision.”
staff competency
1 finding
critical“staff were providing aspects of care outside of their competencies and without appropriate training, supervision, support and guidance.”
end of life care
1 finding
critical“Patients in the palliative home care team (PHCT) did not have individualised care plans that reflected their personal preferences and detailed symptom control and psychological, social and spiritual needs”
leadership
1 finding
critical“Leaders did not fully understand and manage the priorities and issues the service faced. A lack of a leadership structure at local level with unclear responsibilities”
record keeping
1 finding
moderate“Records were stored securely and easily available to all staff providing care. However, records did not accurately reflect patient's needs.”
cultural competency
1 finding
minor“The service did not have information leaflets available in alternative languages. There was no written material, nor any posters or signs on display”