critical“The provider failed to identify, investigate and report safeguarding concerns to CQC or the local authority. For example, when a relative reported an incident where service users living with dementia were locked out of their home”
medication management
1 finding
critical“one person had a medicine prescribed to be given four times a day, but this was recorded as being administered twice daily. This meant the medicine was not being administered as prescribed.”
missed or late visits
1 finding
moderate“Some visits were shorter than agreed times and not always on time... Records showed some people had missed calls.”
care planning
1 finding
critical“A person living with epilepsy had no information in their care plan about how they presented when they had a seizure.”
incident learning
1 finding
moderate“Incidents had not been consistently recorded or responded to. This meant people using the service were placed at risk from potential further incidents.”
governance
1 finding
critical“The provider had not operated an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.”
leadership
1 finding
moderate“The registered manager was not in the service on a full-time basis... they did not have oversight of the quality and safety of the service.”
complaints handling
1 finding
moderate“Complaints which the provider had recorded did not reflect all of the complaints people and their relatives told us they had raised.”
communication with families
1 finding
moderate“Relatives told us communication with the management team was poor and this needed improvement.”
record keeping
1 finding
moderate“Records we reviewed were incomplete or lacked detail and there was little evidence the provider used this information to monitor or improve the service.”