critical“Where people had been prescribed medicines which were to be administered as and when required (PRN), there was no information provided for staff to indicate when these should be given.”
care planning
1 finding
critical“People's care plans provided a list of the care tasks required during each visit but there was limited information on how the person wanted their care provided.”
staff training
1 finding
critical“Certificates showed that staff had last completed training including moving and handling, safeguarding, infection control between 2017 and 2020, which indicated staff did not have up to date training.”
incident learning
1 finding
critical“We reviewed the record of an incident and accident which had occurred...lessons had not been identified and care plans and risk assessments were not updated.”
governance
1 finding
critical“The provider did not have a quality assurance process to enable them to identify if actions were required to make improvement to the care provided.”
safeguarding
1 finding
critical“We saw a safeguarding concern had been raised with the local authority but there were only copies of emails...no review of the possible actions which could be taken to mitigate risks.”
end of life care
1 finding
moderate“People's end of life care wishes were not identified as part of their care plan...the care plans did not include any information on how the person wanted this care provided.”
complaints handling
1 finding
moderate“A complaint had been received...there was no analysis of the issues of the complaint to enable the provider to identify what they needed to introduce to reduce the same issues happening again.”
person centred care
1 finding
moderate“1 person's care plan stated they should be supported with 'a wash' but did not explain how this should be provided to reflect the person's preferences for their care.”
record keeping
1 finding
moderate“The registered manager confirmed they did not carry out formalised quality assurance checks in relation to care plans, the administration of medicines, staff training and the records of care.”
leadership
1 finding
moderate“The registered manager was not aware of the regulatory requirements to send notifications to the Care Quality Commission.”
cultural competency
1 finding
minor“People's care plans did not identify their religious and cultural preferences.”