critical“Risks to people were not always identified, assessed and recorded and staff did not always have access to risk management information”
medication management
1 finding
critical“People who required support to manage their medicines did not have a medicines care plan, risk assessment or medicines administration records (MAR) in place”
staff competency
1 finding
moderate“medicines competency assessments had not been completed to ensure staff were competent to manage and administer medicines safely”
missed or late visits
1 finding
moderate“the gap between the timing of visits can be erratic, there has been hours between visits before”
person centred care
1 finding
critical“care plans did not always identify and or reflect individual preferences in the way people wished to be supported or contain correct information about their needs”
record keeping
1 finding
moderate“one person wore glasses to help them see, but their care plan stated that they had no visual problems. Another care plan documented that the person had no skin integrity issues, however, they required wound dressings”
governance
1 finding
critical“Systems and processes in place for monitoring the quality and safety of the service were not always effective in identifying issues or concerns”
leadership
1 finding
moderate“The service was not well managed... Leaders and the culture they created did not always support the delivery of high-quality, person-centred care”