critical“the care plans provided insufficient detail to give care workers the information they needed to provide personalised care and support that was consistent and responsive to people's individual needs.”
governance
1 finding
critical“Quality audits were not effective as they had failed to identify the issues we have highlighted in this report.”
record keeping
1 finding
critical“in some files no risk assessments had been completed or updated to identify what, if any, action care workers should take to minimise risks.”
consent capacity
1 finding
critical“a care plan for one person whose mental capacity was in doubt did not contain decision specific mental capacity assessments and best interest decisions regarding consent.”
staff competency
1 finding
moderate“medicines competency assessments were not in place to ensure care workers were assessed as competent to support people with their medicines.”
complaints handling
1 finding
moderate“Three formal complaints had been logged, all regarding staff punctuality... there was no evidence of how the complaints had been used to improve the service.”
incident learning
1 finding
moderate“There was a lack of systems in place to enable learning and improvement of performance... no action had been taken to address a concern that had been raised regarding staff punctuality.”
person centred care
1 finding
minor“records reviewed did not contain information highlighting people's diversity, including cultural needs. Therefore, there was a risk that care needs might have been omitted.”