moderate“we identified a concern with someone receiving significantly less time than the service was commissioned to deliver”
critical“Quality assurance audits and checks in some areas of the service were not sufficiently robust to identify issues and take prompt action to remedy.”
critical“Lack of oversight on risk assessment, MAR, call timings and capacity assessments.”
care planning
2 findings
critical“Most care plans and risk assessments were incomplete or not up to date. Staff did not have access to detailed and accurate care records about people's current care needs and risks.”
moderate
“Risk assessments were not always completed to fully document the risks present in people's lives, and guide staff with safe care.”
consent capacity
2 findings
critical“No meaningful mental capacity assessments had taken place which placed people at risk of having decisions made which were restrictive or not in their best interests.”
moderate“Mental capacity assessments were not always in place and did not always contain sufficient detail.”
medication management
2 findings
moderate“We found some gaps in medicine administration charts (MAR) which were not explained. This was not always identified promptly to confirm the reason and take action to remedy.”
moderate“medicine administration records were not always being kept accurately... some medicines were being displayed as either not given, or being given at incorrect times.”
staff training
2 findings
moderate“Some areas of care were not covered in the training programme such as learning disabilities/autism, safeguarding children, oral care, person centred care or the mental capacity act.”
minor“training was required for some staff who were not aware of how to prepare particular foods, due to cultural differences in dietary preferences and cooking.”
record keeping
2 findings
moderate“Information about whether people had made a DNACPR decision was not easily accessible at the time of inspection.”
moderate“Call timings were not always recorded accurately, due to the electronic system not working.”
other
1 finding
minor“some people told us they were frustrated with a lot of new carers and preferred a small team of staff to support them”
communication with families
1 finding
minor“some people told us they felt there was sometimes communication difficulties”
incident learning
1 finding
critical“There was no effective system in place to support lessons being learned when things went wrong...The system to record and analyse incidents and accidents on the new system was not yet established.”