critical“The local authority assessment for a third person indicated they required a soft diet due to digestive problems, but this was not recorded in the provider's care plan.”
medication management
1 finding
critical“Medicines were not audited effectively to help ensure they were administered as prescribed... we saw discrepancies... 'no outcome recorded' but without a reason.”
missed or late visits
1 finding
critical“They come 45 minutes to an hour late sometimes. The majority of the time they are late.”
staffing levels
1 finding
critical“Care workers being recorded in two places at once contributed to this effect... care hours delivered were double the planned amount of care hours.”
governance
1 finding
critical“Systems were either not in place or robust enough to demonstrate service improvement was effectively managed. This was a repeated breach of Regulation 17.”
record keeping
1 finding
moderate“The provider could not tell us how many incidents there had been in the last 12 months, as there was no audit or overview of the incidents.”
incident learning
1 finding
moderate“It was not always clear from the records, how complaints and incidents were responded to, as lessons learnt were not written down to help improve service delivery.”
consent capacity
1 finding
moderate“Two people's care plans had a sentence at the end of them which stated the care plan was agreed by both parties. However, only the Conquest Care representative had signed it.”
staff competency
1 finding
critical“2 of the staff did not have work references or DBS checks back... One staff member did not have proof of their eligibility to work in the UK.”