critical“Care visits were not always completed on time and staff did not always stay for the full duration of the care visits. This increased the risk of harm to people.”
medication management
1 finding
critical“One person required a medicine to manage their pain levels to be given within a 12-hour gap, records did not confirm this was always happening.”
governance
1 finding
critical“Quality assurance processes had not been effective in identifying the issues found at this inspection and in driving the necessary improvements.”
consent capacity
1 finding
critical“Mental capacity assessments were not consistently completed. Records did not always show who was involved in the decision making and if relatives had Power of Attorney.”
care planning
1 finding
moderate“Care plans were not always complete or lacked relevant details about people's care needs.”
incident learning
1 finding
moderate“The provider was not reviewing accidents, incidents, complaints and using this information to learn lessons and avoid reoccurrence of incidents, such as late care visits.”
record keeping
1 finding
moderate“We found several concerns around the quality and accuracy of the records. For example, in relation to risks to people's care, medication and care planning.”
end of life care
1 finding
moderate“People who were in receipt of end-of-life care did not have a specific care plan for this area. Evidence reviewed did not show staff had received training.”
safeguarding
1 finding
moderate“Staff were not aware of whistleblowing procedures to follow if they needed to report concerns outside the service.”
complaints handling
1 finding
moderate“We did not find evidence that complaints received were being used to improve the service.”
person centred care
1 finding
minor“The leadership of the service did not implement an equality, diversity and human rights approach and people's needs were at risk of being frequently overlooked.”
communication with families
1 finding
minor“Although a summary of a survey sent to people was provided, people and relatives told us they had not been asked to complete a survey or a questionnaire.”