moderate“people told us visits were not always delivered on time as planned. The registered manager told us they were working on improving visit times”
critical“Eleven relatives told us that their loved one had their visits missed; seven relatives reported multiple missed visits.”
governance
2 findings
moderate“Governance systems had been established and were operating effectively and the service was working on ensuring the improvements were embedded.”
critical“The provider was not aware of the concerns found during the inspection that had led to people being at risk of not having their needs met and at risk of harm.”
staffing levels
2 findings
moderate“unplanned sickness and absence was a challenge... the service had significantly reduced the number of people using the service”
critical“Staffing levels were unsafe and did not meet the needs of the people using the service. The provider...had continued to take on new packages of care.”
medication management
1 finding
critical“one person should have taken an antipsychotic medicine daily but had not had it for 13 days. The system was not robust and had failed to identify low stock and missed medicines.”
safeguarding
1 finding
critical“We found nine safeguarding incidents during the inspection that had not been identified by the service...The service had not made appropriate referrals to the local safeguarding team.”
care planning
1 finding
critical“A person with a diagnosis of epilepsy did not have specific seizure risk assessments. Their care plans did not include guidance to tell staff what triggers may lead to a seizure.”
complaints handling
1 finding
moderate“We found written records of complaints being phoned into the service by relatives which had not been investigated and responded to.”
person centred care
1 finding
moderate“The service sent male care staff to people who had requested female only staff...relatives told us they had not been contacted and this had caused distress.”
incident learning
1 finding
moderate“Accidents and incidents were not analysed, and concerns were not always investigated. This meant the service did not learn from concerns, accidents, incidents and adverse events.”
infection control
1 finding
moderate“Risks to people's health and welfare had not been assessed in relation to infection prevention and control. Staff were not all taking part in routine COVID-19 testing.”
record keeping
1 finding
moderate“Medication Administration Records (MAR) were not always accurate, kept up to date or completed in accordance with best practice guidance.”
communication with families
1 finding
moderate“This business does not communicate effectively...They need someone on call, not just for us to leave a message, it could be an emergency.”
leadership
1 finding
moderate“There was not a registered manager at the time of the inspection...The structure of the service was not clear. Job roles did not accurately reflect staff responsibilities.”