moderate“We saw in all the care plans that we looked at that there were incomplete sections which meant that staff would not be fully aware of people's care needs.”
minor“care plans did not always contain such detailed information about any specific medical conditions people may have and the implications of this for the support being provided.”
minor“Some risk assessments needing updating to reflect changes in people's conditions.”
missed or late visits
2 findings
moderate“No one came at all one day last week, and They are sometimes around 20 minutes late.”
moderate
“It is like 'hit and miss', you don't know if they are coming or not. Sometimes they miss calls and I have to ring them.”
record keeping
2 findings
moderate“a person had been assessed as at risk of falls and in need of a falls risk assessment but in another section of the record this was not reflected.”
moderate“We identified concerns with the accuracy of the medication recording charts in people's care plans.”
complaints handling
2 findings
moderate“Although the provider was addressing individual complaints, they were not implementing learning from the complaints to improve the experience of people using the service.”
minor“Records showed that the previous registered manager had not always investigated and responded to complaints in a timely manner.”
medication management
1 finding
critical“if a medicine was not administered, the reason and any action taken as result were not consistently recorded and there were gaps in the records.”
governance
1 finding
moderate“feedback was not provided to people and changes had not consistently improved the service.”
person centred care
1 finding
moderate“people had raised concerns about the lack of consistency of staff as they were concerned that staff would not know how to care for them.”