critical“The times are erratic, we never know who or when they [staff] are coming.”
critical“Call log records we looked at showed inconsistencies between planned care times and actual times that staff arrived at people's homes.”
medication management
1 finding
critical“Up to date information was not always held about people's medicines... the person had started to use prescribed cream recently, but staff had not alerted management of this, and therefore MAR were not being used.”
care planning
1 finding
moderate
“Care plans and risk assessments were not always readily available, accessible, or up to date.”
record keeping
1 finding
moderate“There was no system in place to easily find and navigate people's information, care planning, and risk assessments.”
governance
1 finding
critical“systems were either not in place or robust enough to demonstrate oversight was effectively managed. This placed people at risk of harm. This was a breach of regulation 17 (Good Governance)”
person centred care
1 finding
moderate“I can't get on with what I need to do, because I don't know when they will show up.”