critical“Over a period of 23 days, the MAR had been signed nine times and there was no indication why the MAR had not been signed on the other 14 days.”
care planning
1 finding
moderate“Care plans were not always planned in a person centred way so they reflected people's current needs and preferences.”
governance
1 finding
critical“Quality assurance systems such as audits were not being operated effectively. This is the fourth inspection where the service is rated requires improvement with breaches of regulations.”
record keeping
1 finding
critical“Two people were only being cared for in their beds and required repositioning, but the provider did not have a risk assessment around skin integrity for them.”
consent capacity
1 finding
moderate“For others, we found only the agency's assessor had signed the consent form. The provider's processes for identifying and supporting people who lacked mental capacity were not robust.”
person centred care
1 finding
moderate“One person's care plan indicated they should have cream applied to their skin but did not name which cream it was and was not clear where on the person's body the cream was to be applied.”
incident learning
1 finding
moderate“The medicines management systems and checks were also not very effective as they had not identified the concerns we found with the management of medicines.”