critical“staff were not keeping a record of the medicine support given to a person for each individual medicine on every occasion”
moderate“Cream charts were not in use to identify where these should be applied and where they had been applied. There were no patient information leaflets in the care files”
governance
2 findings
critical“Systems and processes and were not robust enough to monitor and improve the quality of the service.”
critical“the registered manager had not undertaken individual formal audits such as care plan audits, daily record audits, staff management of medication, spot check audits”
care planning
1 finding
critical“Care plans were not recorded in a person-centred way to enable an understanding of the person's personal history, individual preferences, interests and aspirations.”
record keeping
1 finding
moderate“the registered provider did not keep a record of The Provision and use of Work Equipment Regulations 1998 (PUWER) and The Lifting Operations and Lifting Equipment Regulations 1998 (LOLER) checks”
staff training
1 finding
moderate“one staff member had not received any training or had their knowledge checked before commencing work on their own and other staff training was out of date.”
supervision appraisal
1 finding
moderate“there was a lack of evidence at inspection to confirm the frequency and the quality of spot checks and supervision.”
staff competency
1 finding
moderate“17 % of people told us care staff did not have the necessary skills.”
missed or late visits
1 finding
moderate“People told us calls were regularly late but they understood why.”
staffing levels
1 finding
moderate“they had been through a difficult time this year, when they did not have enough staff due to the difficulty recruiting in the rural area.”
other
1 finding
moderate“One file we looked at showed that the person had started work before the two references had been obtained.”
complaints handling
1 finding
moderate“Complaints were not compiled to show how the service had analysed and responded to information gathered or used this information to make improvements”
communication with families
1 finding
minor“25 % of people who returned their questionnaire told us the information received from the service was not clear and easy to understand.”
person centred care
1 finding
moderate“care plans remained task focussed and not person centred following review and additional information learnt about people from working with them was not added”
consent capacity
1 finding
minor“staff were unaware of more formalised assessment of capacity and the process required in relation to best interest decision making.”
safeguarding
1 finding
moderate“the safeguarding policy did not contain the telephone or address details of who to contact nor did they reference the local safeguarding policy.”
leadership
1 finding
moderate“both the manager and director had taken leave together and they told us no one else could access all the records we needed to conduct our inspection.”