moderate“They're supposed to come at 9 but it's 9.45. We found inconsistent call times in place for 6 people we reviewed.”
governance
1 finding
critical“Governance systems were not robust or effective enough to monitor and improve the quality and safety of the service provided. Breach of regulation 17.”
record keeping
1 finding
moderate“Daily records were not completed when staff had attended to people's care. This meant the provider could not be sure that people had received their assessed care.”
leadership
1 finding
moderate“The management oversight in place for when the registered manager was absent was not clear.”
care planning
1 finding
moderate“Detail was basic in daily notes and did not capture the care delivered to people. This meant the provider could not be sure people received their agreed care.”
medication management
1 finding
minor“Some staff had limited knowledge of what the medication was that they were administering. One person told us, 'I have to tell them what my medication is, then they give it to me'.”
end of life care
1 finding
minor“We did identify a gap in the training provided, this being around end-of-life care.”
staff competency
1 finding
minor“Some people we spoke with told us that staff did not always read the care plan. 'These new ones they're on their phones so I have to tell them what to do'.”