minor“Where improvements to the service had been identified through quality auditing, action was not always revisited and signed off.”
moderate“internal audits were not completed on an appropriate scale...a maximum of seven Medication Administration Records (MARs) were audited on a monthly basis even though the service supported over 200 people”
communication with families
2 findings
minor“Some people said the office staff do not answer the phones, speak in an unprofessional manner, and do not act on concerns shared.”
minor“a small number of people told us phone calls to the office had been unanswered...Two people told us they experienced some difficulty in getting through to office staff”
medication management
2 findings
moderate“we found this action had been completed for some staff teams, but not all...further work and improvements were needed to ensure all teams were completing the records appropriately”
moderate“we reviewed 15 people's MARs and identified gaps in 10 of these records...this gap in recording could lead to errors occurring and people not receiving their medicines as prescribed.”
missed or late visits
1 finding
moderate“"Normally there is a lot of variation in visit arrival times" and "They come to visits at anytime, I've had to cancel hospital appointments as the carers were late."”
record keeping
1 finding
minor“the quality of person-centred information varied in different people's care records. The registered manager acknowledged this and confirmed they had identified improvements were needed”
person centred care
1 finding
minor“staff had talked to them about their preferences for their care, although we found some of this information had not always been incorporated into the care plans”
staff training
1 finding
moderate“training matrix showed that a high number of staff required training in a wide range of areas including, safeguarding vulnerable adults, the Mental Capacity Act 2005, moving and handling, infection control”
care planning
1 finding
moderate“at the time of our inspection 69 annual reviews needed to be completed. This meant we could not be sure if care reflected people's needs, wishes and preferences.”
complaints handling
1 finding
minor“one person had not received a response to their complaint for eight weeks. The registered manager explained the investigation has been delayed due to staff sickness”
incident learning
1 finding
moderate“no accident or incident...had been recorded in the previous 60 days...Failing to record incidents that staff witness or become aware of could lead to people not receiving the care or medical attention they require”