critical“people were not always protected from abuse because the provider failed to identify when abuse had taken place”
medication management
1 finding
critical“we found major concerns in relation to one person who had been administered medicine not prescribed for them for a week without the provider noticing.”
governance
1 finding
critical“Governance arrangements had not operated effectively to improve the quality and safety of the service.”
care planning
1 finding
moderate
“risk assessments were unclear and did not provide guidance on how some risks should be managed.”
incident learning
1 finding
moderate“records of incidents reviewed did not demonstrate the outcomes and where there had been learning from them.”
person centred care
1 finding
moderate“Care plans provided details of people's needs, however they were not always person-centred.”
complaints handling
1 finding
moderate“the provider was aware that aspects of the procedure were not always followed, such as informing people of the outcome of their complaint in writing.”
missed or late visits
1 finding
moderate“Some of the concerns identified included missed visits.”
record keeping
1 finding
moderate“they had failed to identify that the care records were not accurate, risk assessments were not detailed and care plans were not person centred.”
staff competency
1 finding
minor“I don't think she has been trained to deal with mental health issues... she just doesn't have the background for dealing with mental health.”