moderate“one person was identified as being at risk of falls, a management plan for this risk was not completed but commented on in places throughout the care plan”
governance
1 finding
critical“failure to operate effective systems to assess, monitor and improve the service...was a breach of Regulation 17 (Good governance)”
record keeping
1 finding
moderate“Care plans had not been consistently updated with new information and changes for people and their needs, in a timely way”
missed or late visits
1 finding
moderate“One visit can be in and out in 9 minutes, meant to be 30-minute visit”
staffing levels
1 finding
moderate“Staff gave mixed feedback when asked if there were enough staff to support people who use the service...Not enough staff, staff come and go”
consent capacity
1 finding
minor“one person's capacity assessment record did not include information on efforts made to include the person in the assessment”
person centred care
1 finding
minor“people's feedback were regularly sought by the management team, however actions taken in response to this feedback, were not always recorded”