critical“One care plan stated the person could transfer and use a wheelchair; this person was immobile. Another care plan did not include known risks around suicide ideation.”
moderate“staff were assisting one person with a continence product that was not planned for... care plan simply said staff should 'assist' the person with tasks, but did not include what assistance they required”
medication management
2 findings
critical“Medicines records were at times contradictory and confusing. Staff were not always recording the amount of medication, or the times medicines were administered.”
minor“One person was prescribed creams but these were not recorded on the medicines records; during the inspection this was corrected.”
governance
2 findings
critical“Audits had not identified and resolved the shortfalls we had identified on inspection in relation to care records and medicines administration concerns.”
critical“Systems to assess, monitor and improve the quality of the service had not been operated effectively. We found there was no systematic approach to quality assurance.”
care planning
2 findings
moderate“Documentation did not include all the information to guide staff around how to provide safe care and treatment. Care records did not always reflect accurate information.”
moderate“records for six people... were not always accurate, up to date and reflective of people's current circumstances.”
incident learning
2 findings
moderate“Accident and incident records did not have enough information to look for themes and prevent the events from happening again in the future.”
moderate“we also found incidents where there was no record of action having been taken at the time of the incident.”
missed or late visits
1 finding
minor“There were times when care staff were late to calls and people told us they do not always get notified.”
staffing levels
1 finding
moderate“last minute changes to rotas, not enough travel time between calls in different areas, staff being told to attend two-carer calls on their own”