critical“Risks were not consistently assessed and planned for. There was a lack of information about how risks associated with conditions such as epilepsy and diabetes might impact on the care being provided.”
medication management
1 finding
critical“Staff were not always following safe systems and processes to administer and record medicines. We identified a medicines' error the providers own checks had not identified.”
record keeping
1 finding
critical“There was often no suitably detailed record in place to document what specific medicines and topical creams had been prompted or administered.”
staffing levels
1 finding
moderate“Staff member told us, 'No, three quarters of the time this is really a challenge, and it puts a strain on me as a carer trying to make up for lost time travelling in-between the clients when there is no travel time allocated.'”
missed or late visits
1 finding
moderate“People told us, 'I never know what time, they are going to turn up' and 'They normally come late even though we have asked for an early call'.”
governance
1 finding
critical“The provider had not identified all of the shortfalls prior to our inspection and therefore prompt action had not been taken to make improvements.”
staff competency
1 finding
moderate“A number of competency assessments were outstanding. The registered manager assured us these would be completed by the end of April 2023.”
consent capacity
1 finding
moderate“In some cases, the information available in people's support plans indicated the person might lack capacity to make decisions about their care, but there were no mental capacity assessments in place.”
person centred care
1 finding
moderate“When assessing people's needs, staff had not always ensured people's unique personal histories and cultural or spiritual beliefs were explored.”
cultural competency
1 finding
minor“Some of the language used in a small number of these records was not fully person centred... due to the largely international staff coming from a range of different cultures.”