critical“governance systems were not effective in monitoring the quality of the service or driving improvements. This is a breach of Regulation 17 of the Health and Social Care Act 2008”
care planning
1 finding
moderate“people did not have specific care plans in place for living with epilepsy, dementia, substance misuse, support to eat and drink or support with pressure area care”
missed or late visits
1 finding
moderate“sometimes staff show up at [time] and sometimes another [time]. It can vary a lot and sometimes they stay the full time and sometimes only for a few minutes.”
record keeping
1 finding
minor“daily notes did not record how people were feeling and only recorded what support staff had given in relation to essential care needs such as personal care”
incident learning
1 finding
critical“The provider had not informed us of statutory notifications which they are required to do so by law. For example, they had not let us know of serious injuries to people such as pressure sores”
communication with families
1 finding
minor“There was limited information in people's care plans relating to how staff could communicate with them. The management team did not share any documents with us which had been produced in an easy read format.”