critical“in one person's MAR, the amount of medicines to be given to them was not recorded, therefore staff would not know how many were to be administered”
missed or late visits
1 finding
critical“Systems were not in place to monitor missed and late visits. Some people had missed visits which put them at risk of harm.”
safeguarding
1 finding
critical“The provider did not always recognise and act upon the potential safeguarding implications of how people were affected by missed and late calls.”
governance
1 finding
critical“Systems or processes were not being operated effectively for the management and oversight of the service.”
staff competency
1 finding
moderate“Assessments on staff members competency to administer medicines were not robust. We saw one assessment which had been completed with one staff member over the phone.”
staff training
1 finding
moderate“no oral hygiene training, basic first aid or pressure care management training was shown to be in place.”
care planning
1 finding
critical“care plans did not provide adequate information about how to meet people's needs. This was a continued breach of Regulation 9”
record keeping
1 finding
moderate“Written paperwork such as daily notes and medicine administration records were illegible and disorganised”
infection control
1 finding
moderate“The provider's infection prevention and control policy and COVID-19 policy did not follow good practice guidance and had not been reviewed”
consent capacity
1 finding
moderate“There was little evidence of formal capacity assessments or detailed best interest decision making within the care plans of people living with dementia.”
incident learning
1 finding
moderate“no analysis of trends and common themes were looked into to ensure they didn't happen again.”
communication with families
1 finding
moderate“over half of people said they were not happy with communication and being informed of changes.”
leadership
1 finding
moderate“I really feel that the office and management is a real problem. They do not listen.”
other
1 finding
critical“We found gaps in the employment history of staff which had not explained or recorded in all the files we looked at.”