critical“Ineffective quality monitoring systems could place people at risk of harm, and this is a breach of regulation 17, Good governance, of the Health and Social Care Act 2008.”
missed or late visits
1 finding
critical“There were no monitoring systems to ensure calls were not missed. Two people told us they had experienced a missed call. This placed people at risk of harm.”
medication management
1 finding
critical“Medicines competency assessments were carried out by the registered manager. However, we found the registered manager lacked knowledge of some questions they had assessed staff members of being competent.”
care planning
1 finding
moderate“There were no monitoring processes to ensure prior to people accessing the service, they were subject to a needs assessment.”
end of life care
1 finding
critical“There was no end-of-life care plan in place for the person... resuscitation could take place against the person's wishes, due to official documentation not being accessible.”
consent capacity
1 finding
moderate“The registered manager could not be assured these family members had a legal right to make decisions on behalf of the person.”
communication with families
1 finding
moderate“The registered manager was unaware of the Accessible Information Standard and there were no systems in place, should anyone in the future require support with communication.”
cultural competency
1 finding
minor“There was no emphasis focused on equality and diversity during the assessment and care planning and this meant people needs may not be met the way they wanted.”