moderate“Body maps were not always used effectively to show where topical creams should be applied. Records did not clearly show how risks related to emollient creams should be mitigated.”
moderate“Audits used to monitor medicines identified these gaps, but the provider did not always take action informed by these audits.”
record keeping
2 findings
moderate“Some care and medicine records lacked detail about the care provided to people. Audits and reviews of care records were carried out at the branch but had not identified gaps.”
moderate“We saw gaps and errors in recording in Medication Administration Records (MARs) from people's homes.”
governance
2 findings
moderate“Provider governance was not always effective in identifying areas for improvement...these did not identify improvements required in care records.”
moderate“Management staff and the provider did not monitor shifts where a support worker had arrived late or where missed shifts had been covered by an agency staff member.”
consent capacity
1 finding
moderate“The service did not always robustly record assessment of mental capacity and how decisions were made in people's best interests.”
care planning
1 finding
moderate“Some risk assessments were focused on organisational or generic risks, rather than those experienced by the individual person. Risk management plans therefore sometimes lacked detail.”
staffing levels
1 finding
critical“Staff let you down at the last minute, it makes it difficult not knowing that staff aren't going to come.”
missed or late visits
1 finding
critical“A shift had been missed for three consecutive nights and that due to this the family had changed their care provider.”
staff competency
1 finding
moderate“A commissioner told us that staff did not always have the relevant experience and training.”
supervision appraisal
1 finding
minor“Staff told us there had been a gap in team or peer meetings since the change in manager.”
leadership
1 finding
moderate“At the time of our inspection, there was no registered manager.”