moderate“where people did not have the capacity to consent to their care, relatives without the legal authority to do so, had signed to give their consent to the care provided”
critical“family members had signed on behalf of their relatives but there was no clear indication of why the person who used the service was unable to sign the care plan.”
end of life care
1 finding
minor“Care plans did not include people's end of life wishes.”
medication management
1 finding
critical“MAR charts were not being audited by the service so there were no checks and balances in place to ensure care workers were administering medicines correctly and safely.”
care planning
1 finding
critical“one file indicated the person self-harmed but there was no risk management plan for how to minimise the risks, what signs to be aware of or how to manage the behaviour.”
governance
1 finding
critical“they did not always record outcomes or analyse service information such as incidents and accidents, nor did they have written audits for medicines or finance.”
incident learning
1 finding
moderate“Details of the incident were described but there was no record of the follow up or analysis of trends recorded to improve future service delivery.”
staffing levels
1 finding
minor“Some relatives commented that the service would benefit from more care workers and two care workers said sometimes they would like to have more time for calls or between calls.”
record keeping
1 finding
moderate“care records and care workers' files lacked audits to ensure files contained evidence that systems were being followed.”