critical“Another person had no MARs in place for the months beginning December 2022 and January 2023. There were no records to show that they had received their medicines safely as prescribed.”
missed or late visits
1 finding
critical“22% of calls were more than 15 minutes late, and 9% were more than 45 minutes late...31.6% of care visit calls were scheduled without allowing staff any travel time.”
care planning
1 finding
critical“Care plans did not always identify and or reflect individuals' preferences...Some care plans and records contained contradictory and or inaccurate information.”
governance
1 finding
critical“The registered manager confirmed and acknowledged that there were no systems in place to check and audit care records and care plans.”
safeguarding
1 finding
critical“Records showed that safeguarding concerns, complaints and accidents and incidents were not always correctly identified, assessed, and respond to in line with the providers policy.”
consent capacity
1 finding
critical“Mental capacity assessments that had been completed, had not been completed correctly...not detailed nor decision specific. They failed to detail the questions asked.”
complaints handling
1 finding
moderate“Complaints were not always managed appropriately and in a timely manner and audits in place to learn from or identify themes and trends were not always effective.”
staff competency
1 finding
moderate“Medicines competency assessments had not been completed to ensure staff were competent to manage and administer medicines safely.”
end of life care
1 finding
moderate“Care plans and records did not include information regarding people's end of life care, wishes and preferences.”
person centred care
1 finding
moderate“Care plans and records had limited information about people's personal histories, lifestyles, preference, and independence.”
incident learning
1 finding
moderate“The provider did not ensure lessons were learned when things went wrong and did not have robust systems in place to ensure reported safety concerns were addressed.”
record keeping
1 finding
moderate“There were no body maps in place to guide staff on where the patch needed to be applied ensuring rotation of the patch site in line with guidance and best practice.”
staffing levels
1 finding
moderate“13% of double handed care call had less than 15 minutes overlap between care workers, including 8% which had no overlap.”