critical“The service had not implemented any quality assurance systems to monitor the quality and safety of the care provided.”
record keeping
1 finding
critical“Paper records completed by staff and management were not held in a consistent format or securely fastened into a folder.”
consent capacity
1 finding
critical“No mental capacity assessments had been carried out in the care plan and there had been no review following the concerns raised by staff.”
care planning
1 finding
moderate
“Care plans did not have a consistent format. Each one we reviewed included slightly different documents. Information was not held securely.”
supervision appraisal
1 finding
moderate“Staff did not receive regular supervision and appraisal in accordance with the providers policy. There was no record of staff appraisals.”
medication management
1 finding
moderate“The MAR just stated 'Medicines given' with no detail of what the individual medicines were.”
safeguarding
1 finding
critical“The combinations to the key safes, used by staff to access keys to a property...was clearly recorded in the visit guidance for staff and on the front page of the care plans.”
incident learning
1 finding
moderate“There was no consistent process in place for staff to escalate this concern...next recorded entry was not made until the next planned visit at 11.30 am the next day.”
person centred care
1 finding
minor“Some people's needs were changing and although we were assured by people, relatives and staff that needs were being met, this was not always recorded in the care plans.”