critical“Care plans lacked detail how people's individual care needs were best met and were not person centred.”
person centred care
1 finding
critical“We viewed eight care plans and found that they all lacked detail and personalisation. The service used the same template for all people which had identified the same six needs.”
incident learning
1 finding
critical“Accidents and incidents were not always documented in a timely manner and trends and patterns were not analysed and action taken.”
governance
1 finding
critical“The service internal monitoring system from July 2022 to September 2022 did not highlight the shortfalls in the management of risk and planning of person-centred care”
consent capacity
1 finding
critical“The service was not working within the principles of the MCA. We found little evidence that the service had undertaken assessments of people's capacity”
medication management
1 finding
moderate“risk assessments for people who received support around their medicines were not always comprehensive and lacked the necessary information for staff to support people safely with their medicines.”
record keeping
1 finding
moderate“one risk assessment from December 2019 had not been reviewed or updated. Therefore, it was not clear if the person's changing needs had been addressed”
missed or late visits
1 finding
moderate“we found evidence of 'call cramming', which meant care workers did not have sufficient travel time.”
communication with families
1 finding
minor“one care plan stated that the person was hard of hearing but there was no further information how the person was supported around this.”
leadership
1 finding
moderate“The service lacked a positive person centred, open, inclusive and empowering culture.”