critical“MARs had not always been completed to confirm staff had administered people's medicines as prescribed... those records were not reviewed or checked by managers.”
critical“Guidance to inform staff when 'as required' medicines needed to be given was not in place. That meant people could have been given too much or not enough of their medicines.”
governance
1 finding
critical“The provider had failed to operate effective governance systems. For example, audits of care records and risk management plans had not identified the shortfalls we found.”
care planning
1 finding
moderate
“The amount of information contained within people's care records varied. Some care records focussed on the tasks staff needed to complete.”
consent capacity
1 finding
moderate“mental capacity assessments had not been completed when required to determine if people could make their own decisions to ensure their rights were upheld.”
infection control
1 finding
moderate“Risks associated with COVID-19 had not always been assessed in line with the providers policy and national guidance.”
incident learning
1 finding
moderate“the provider did not have an effective system in place to monitor, manage and reflect on incidents to prevent reoccurrence.”
complaints handling
1 finding
moderate“five complaints had been received about late calls in the 12 months prior to our visit. This indicated opportunities to identify where quality could have been improved had been missed.”
record keeping
1 finding
moderate“Risk management plans did not always contain the information staff needed to provide safe care.”
staff training
1 finding
minor“Training records we viewed were not up to date and one staff member was not listed on the providers training matrix.”
missed or late visits
1 finding
minor“It was a bit chaotic with timings over the summer, staff did turn up but not always on time. I think they [staff] had too many people to look after.”
communication with families
1 finding
minor“People's communication needs, and preferences were not always assessed or documented to help staff communicate with people well.”
cultural competency
1 finding
minor“assessments needed to be further developed to ensure protected characteristics under the Equality Act 2010 including people's cultural needs were fully considered.”
leadership
1 finding
moderate“The service did not have a manager registered with the Care Quality Commission in line with the requirements of the provider's registration.”