critical“We found serious complaints that had been raised by people or their relatives had not been referred to the local authority safeguarding team for an independent investigation and review.”
missed or late visits
1 finding
critical“missed calls had been identified in May, June and September placing people at risk of not receiving the support they needed.”
medication management
1 finding
critical“Two people were not supported with their medication over a period of a weekend due to missed calls. This placed them at serious risk of harm due to not receiving their prescribed medication.”
incident learning
1 finding
critical“The provider had identified the need to implement an electronic call monitoring system following an episode of calls being missed. However, at the time of inspection this had not been implemented.”
governance
1 finding
critical“The provider and registered manager failed to have good governance systems in place. This was a continued breach of regulation 17 (Good Governance).”
care planning
1 finding
moderate“Risk assessments were in place but did not always contain all the information needed to support people appropriately.”
staff training
1 finding
moderate“The relieve carer had been given no training on how to administer insulin.”
staffing levels
1 finding
moderate“they had continued to find recruitment difficult leading to shortages with staff to provide care and support to people.”
complaints handling
1 finding
moderate“where some complaints should have been escalated to a safeguarding investigation which had not been done.”
record keeping
1 finding
moderate“Part of this risk assessment was to keep records and receipts for money spent, we found no records had been kept.”
person centred care
1 finding
moderate“a person's choice of whether received care from a male or female member of care staff was frequently disregarded even when they raised a complaint about this.”
consent capacity
1 finding
minor“where best interest decisions were in place these needed to be less generic.”
communication with families
1 finding
moderate“We get the obligatory monthly phone call but it's so generic and nothing happens even when issues are raised.”