critical“Medicines were not always administered safely... We observed this had not been completed in two people's records. In another person's record it had been completed incorrectly.”
care planning
1 finding
critical“where risks had been appropriately identified the risk management plans were not always robust enough to clearly inform staff of the action needed to take to minimise the risks”
person centred care
1 finding
critical“People's care was not always personalised. There was no information recorded on how people would like their personal care to be delivered and very limited information about people's lives”
consent capacity
1 finding
critical“The provider's processes for identifying and supporting people who lacked mental capacity were not robust... The provider had not always completed capacity assessments”
governance
1 finding
critical“Quality assurance systems such as audits were not being operated effectively as demonstrated by a number of shortfalls identified during the inspection.”
missed or late visits
1 finding
moderate“Relatives raised late calls as an ongoing issue, yet the provider had not prioritised monitoring call times to ensure people received their care at the agreed times.”
communication with families
1 finding
moderate“People were not always notified when care staff were running late.”
incident learning
1 finding
moderate“there were no effective systems in place to analyse incidents and accidents to ensure lessons could be learnt to reduce the likelihood of an incident reoccurring”
end of life care
1 finding
moderate“The registered manager was only recording information that was collated at the referral assessment stage, this meant staff did not have important information about what was important to care for people who were at the end of their life.”
record keeping
1 finding
moderate“Accurate, complete and contemporaneous care records were not always maintained.”
cultural competency
1 finding
moderate“People's protected characteristics under the Equality Act (2010), such as religion and disability were not recorded, and we could see no evidence if these were discussed with people”