moderate“Timings are poor, occasionally they call us to tell us they're running late.”
moderate“Call logs showed that staff were often late and relatives told us staff seemed rushed. One relative told us, 'I can't remember the last time the carers came at the proper time.'”
communication with families
2 findings
moderate“[My relative] has trouble understanding the carers, there is a language barrier. It is a mutual not understanding.”
moderate“relatives told us they weren't always informed when care staff were late. One relative told us, 'I ring up to find out where the carers are... I never get a phone call to tell me.'”
person centred care
2 findings
critical“1 document still referred to a person as having a 'normal' background.”
moderate“People were not always supported in a person-centred way that reflected their wishes and preferences. Relatives told us this was because staff did not always have time to do this.”
governance
2 findings
critical“Systems had not been established to ensure the quality and safety of the service was assessed, monitored and improved effectively.”
critical“Systems had not been established to ensure the quality and safety of the service was assessed, monitored and improved effectively. This placed people at risk of harm.”
care planning
2 findings
moderate“People's diverse needs under the Equality Act 2010 were recorded on their assessments but failed to identify how staff should support them.”
moderate“People's care plans were inconsistent and were not always reviewed regularly... care plan documentation was not always accurate.”
end of life care
2 findings
moderate“People did not have end of life support plans in place and there was no evidence that people's wishes and feelings at that stage of their life had been discussed.”
minor“People's end of life wishes and preferences had not been considered in their care plans.”
consent capacity
2 findings
minor“The assessments were generic and did not record which decision the assessment was in relation to.”
critical“Mental capacity assessments were not completed when required... people were not always able to consent to care and treatment in line with the law.”
record keeping
2 findings
moderate“Quality checks did not identify where assessment documentation was not always consistent with people's care plans.”
moderate“Checks were not sufficient to ensure information had been transferred over from paper records to electronic records accurately. This meant there were inconsistencies in people's care plans.”
cultural competency
2 findings
minor“Assessment records did not always contain appropriate language to describe people's backgrounds.”
minor“Staff sometimes conversed with each other in a language that people did not understand which relatives found disrespectful.”
infection control
1 finding
moderate“One relative told us staff did not always use sterile water and clean equipment which was needed to meet their relative's needs.”
medication management
1 finding
critical“one person was administered the incorrect medicine which resulted in paramedics being called... one person had received a double dose of medicine which placed them at risk of harm.”
safeguarding
1 finding
critical“staff who told us they had not received safeguarding training and did not always understand how to keep them safe. One staff member told us, 'I've not had safeguarding training'”
staff training
1 finding
critical“relatives told us staff did not always seem knowledgeable about the needs of people living with dementia... not all staff were up to date with their training.”
supervision appraisal
1 finding
moderate“Staff supervisions were undertaken when there had been a concern raised... However, they were not always undertaken regularly to enable the registered manager to identify any potential training needs.”
incident learning
1 finding
moderate“not all accidents and incidents were recorded which meant that this analysis was not always accurate... where call times were cut short, they were not always investigated.”
complaints handling
1 finding
moderate“Recording of complaints and concerns was not consistent. Some issues had not been formally recorded and investigated in line with the provider's complaints policy.”
staff competency
1 finding
moderate“staff did not always have sufficient English language skills or knowledge about specific health conditions they needed to meet people's needs safely.”