critical“risk management plans had not been put in place for all identified risks. For example, a risk management plan for the use of a catheter had not been developed”
critical“People's care plans were not always person centred and did not always identify how people wanted their care provided.”
record keeping
2 findings
critical“a risk assessment in relation to choking had not been reviewed since May 2020...the provider had not ensured information was up to date and that staff were following the correct guidance”
moderate“The care plan for one person indicated they experienced a change in support needs following a hospital admission in January 2021, but the care plan had not been updated.”
incident learning
2 findings
critical“falls risk assessments for two people had not been updated following them experiencing a fall. One person had a fall in November 2021 and in July 2021, but their falls risk assessment was last updated in June 2021”
critical“One person had experienced a fall in February 2021...there was no record of any action taken. The person's falls risk assessment and care plan had not been updated.”
governance
2 findings
critical“provider's checks on care plans were not effective in relation to monitoring if a person's consent was received for the care being provided or if best interests decisions were made”
critical“Audits were carried out of the completed MAR charts...where issues had been identified actions had either not been recorded, or if they had there was no evidence these had been completed.”
consent capacity
2 findings
moderate“A mental capacity assessment and best interests' decision were not in place for these aspects of care to identify if the person could consent”
critical“The provider could not ensure the relative consenting to the person's care had the legal right to do so under the MCA.”
medication management
2 findings
moderate“MAR for this person indicated a medicine...should be administered in the evening but the records showed it was being administered mid-afternoon”
critical“MAR charts did not always include the dosage of the medicines and the frequency of administration.”
person centred care
2 findings
minor“records of the care provided during each visit which were completed by the care workers were not always person centred and were task focused”
moderate“The records of care completed by care workers following each visit were not always person centred and were focused on the tasks completed and not the person's experience.”
safeguarding
1 finding
critical“A concern had been referred to the local authority safeguarding team and had been investigated in August 2020 but they had not sent the required notification.”
end of life care
1 finding
moderate“End of life care plans did not always refer to the person's end of life wishes and used identical wording for different people.”
staff competency
1 finding
moderate“Two care workers were last assessed [for medicines competency] in 2019, one in January 2020 and there was no competency assessment on file for the fourth care worker.”