critical“Staff told us that a person was locked in their house by staff when staff were not there. We were concerned that this person was being unlawfully restricted.”
critical“People's care plans contained conflicting and confusing information about their mental capacity. The best interest part of the assessment had not been recorded or completed.”
medication management
1 finding
critical“Medicines that should not be given with food or other medicines were administered incorrectly. A person's MAR showed staff were administering thyroid medicine at the same time as other medicines.”
care planning
1 finding
critical
“Risk assessments relating to moving and handling did not provide clear guidance on safe ways of working and had not incorporated the very detailed instructions from occupational therapists.”
governance
1 finding
critical“Audits had not picked up shortfalls in practices in relation to risk assessment, medicines management and mental capacity.”
safeguarding
1 finding
moderate“The safeguarding policy gave staff incorrect information about which local authority to address concerns to. Not all staff understood safeguarding and what to do if they suspected abuse.”
staff training
1 finding
moderate“Some staff lacked knowledge around training in topics such as catheter care, safeguarding and diabetes. Some staff carrying out risk assessments had not received training to support them.”
record keeping
1 finding
moderate“Information obtained from local authority care plans which had been sent to the service as part of the referral had not been included in the care plan available for staff.”
missed or late visits
1 finding
minor“Travel time was not always enough time for staff to travel from one side of Maidstone to the other in peak times. This sometimes impacted on people's call times.”