FDR Social Care

Care plans did not accurately reflect medication people were taking. Where care worker occasionally applied creams to people’s skin, there was not full information about what these creams were or where or when they should be applied. Information about people’s medication was not up to date in their care plans. This constituted a breach of Safe Care and Treatment. Mental capacity assessments did not have accurate information. The service had commissioned an external audit of their records but the recommendations from this had not been fully actioned. There had been improvements in safeguarding and there was a robust recruitment process in place to ensure safe and effective staffing.

People and their families were confident that their individual needs had been appropriately assessed and fully understood. People were involved as much as possible in the assessment of their needs and were supported by their families to do so. Care workers told us how they ensured the person being supported was involved in day-to-day decisions and consented to the care delivered. However, reviews were not carried out in a timely fashion and new information from reviews was not updated in all care plan documents. Consent to care plans had not been signed by the person receiving support and it was not clear who had signed these or what authority they had to do so. Information about people’s protected characteristics required more depth.

People were supported and always treated with dignity and respect. Their wishes and choices were understood and respected by care workers, and they were supported to live as independently as possible. People’s relatives described staff as kind, considerate and empathetic. However, there was limited evidence that people’s protected characteristics and communication needs had been fully assessed and considered in care planning.

We saw evidence that people and their relatives had the opportunity to share their views about the service. There were provisions in place to ensure smooth handover between services. Care plans had limited information about people’s protected characteristics and information about communication abilities was inaccurate. The service had not been proactive in seeking out information about cultural and religious backgrounds.

Governance systems did not consistently identify where improvement in documentation was needed. Care plan audits did not identify the issues seen during this assessment. This constituted a breach in Good Governance. However, there was a positive culture within the service and care workers felt able to raise concerns if they had them.