critical“Medicine processes were not safe. People did not always receive their medicines at the correct time, and oversight was not effective nor robust.”
critical“some protocols and procedures required improvement. Where people were prescribed variable dose medicines...guidance needed to be expanded for staff.”
critical“medicines were documented on the medicine administration record to be given at the same time as all other morning medicines.”
care planning
2 findings
critical“Care plans were not personalised and did not reflect the required support needs and preferences of people. This was a breach of regulation 9.”
critical
“one person's pressure sore risk assessment stated the person was fully mobile, when their mobility was restricted.”
governance
2 findings
critical“The provider had failed to ensure systems had been robustly reviewed since our last inspection. The breaches of regulations had not been considered holistically.”
critical“audits and governance systems had not identified specific areas for improvement which had been found during this inspection.”
staff training
2 findings
moderate“Long standing staff had not consistently completed training which new staff received during their induction. This included key topics such as skin, continence and catheter care training.”
moderate“Staff had completed training relating to the Mental Capacity Act...however, were unable to explain their understanding, and how they would apply the principles in practice.”
record keeping
2 findings
moderate“One person's care plan stated staff should leave their left-side bedrail down... however, the risk assessment did not contain this information, was generic.”
moderate“Another person's medicine risk assessment did not detail their medicine allergies...two people were prescribed nutritional supplements due to a risk of malnutrition, however, this detail was not included.”
person centred care
2 findings
moderate“People did not always feel included in all aspects of their care, including the planning and knowledge of care visit timings. People told us this impacted negatively on their day to day lives.”
minor“Some people, and their representatives, told us they sometimes experienced language barriers with staff...they talk to each other in a different language which I find rude.”
communication with families
2 findings
moderate“one person told us, 'They don't let me know if carers are going to be late.'”
moderate“If you ring up, they say they will let [specific staff member] know, but you never get a call back unless they want something from you.”
safeguarding
1 finding
critical“Systems and processes were not robust to protect people from abuse. Staff had received safeguarding training, however, some incidents where potential abuse took place were not recognised and reported.”
missed or late visits
1 finding
critical“A care visit had taken place for a person at 05:59am when their agreed care visit time was 07:30am... People's care visits were not scheduled for their agreed times.”
staffing levels
1 finding
critical“There were not enough staff to meet the needs of people. People experienced variable planned call times which were not reflective of their contractual agreements.”
incident learning
1 finding
critical“The registered manager was not aware of this incident, and we were therefore not confident in reporting practices and oversight.”
infection control
1 finding
moderate“People considered vulnerable did not have individual COVID-19 risk assessments in place. Guidance was therefore unavailable to staff to mitigate risk.”
complaints handling
1 finding
moderate“One person said, 'The office doesn't take notice of my concerns, the boss never rings me back.' A third person said, '[It's] not worth doing as nothing changes.'”
leadership
1 finding
critical“The registered manager and provider lacked oversight in key areas which placed people at risk of harm. Clear and effective quality assurance systems were not embedded at the service.”
staff competency
1 finding
moderate“we found staff were unable to evidence an effective understanding of all training that had been completed.”