critical“Since 29th April 2023 there had been 8 medicine errors. This included overdosing and under dosing of medicines.”
governance
1 finding
critical“The provider had failed to ensure effective and robust governance systems were in place to ensure the health and wellbeing of people who use the service.”
person centred care
1 finding
critical“The outcomes people wanted from their care and support had been copied and pasted from one person's care plan to another.”
care planning
1 finding
moderate“A falls risk assessment was not in place for someone who had previously fallen. People's care and support plans were not consistently person centred.”
consent capacity
1 finding
moderate“It was not always clear if the provider was working within the principles of MCA...documentation was not always in place to support this.”
end of life care
1 finding
moderate“The service was supporting one person who received end of life care but there was a lack of information about their wishes and preferences.”
missed or late visits
1 finding
moderate“Out of the 109, 79 occasions recorded that the staff did not stay for the correct amount of allocated time for the call.”
incident learning
1 finding
moderate“The registered manager had not consistently notified the Care Quality Commission of notifiable incidents.”
complaints handling
1 finding
minor“One person told us, 'Yes I have had to make a complaint, but it falls on deaf ears.'”