critical“Another person was diabetic. There was no risk management plan to tell staff what to do and signs to look out for if the person's blood sugar levels were too high or too low.”
critical“Risk assessments and risk management plans were not always in place to protect people from the risks of recognised health conditions.”
moderate“some required more detail to ensure staff had enough information to support people with specialised mobility equipment such as banana boards and continence aids”
moderate“Care plans did not contain evidence of a detailed needs assessments and some people told us they had not completed a care plan with the provider.”
governance
4 findings
critical
“Statutory notifications had not always been sent to us for notifiable incidents. This is a legal responsibility and we could not be confident we had been informed.”
moderate“Some completed audits and resulting actions remained in the people's homes and were not kept centrally...registered manager's did not have good oversight of the quality of care.”
critical“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17”
critical“Audits did not identify serious concerns with recruitment and numerous other areas... the lack of robust quality assurance meant people were at risk of receiving poor quality care.”
infection control
3 findings
moderate“The registered manager did not undertake any health screening questions, take our temperature or ask if we had any COVID-19 related symptoms.”
moderate“The provider did not always dispose of used PPE effectively and safely...transported it to their sister care home for disposal in their clinical waste...not in line with government guidelines.”
minor“we received some concerns from people that staff were not always effectively following infection control guidance in their everyday practice”
medication management
3 findings
critical“A medicines audit signed as completed on 5 January 2021 and with no errors, had unexplained omissions...Medicines administration records...did not have the dosage required.”
moderate“more detail was needed to ensure these were given safely and consistently by staff”
critical“Medicine administration records (MAR) contained little or no information about the medicines people should be receiving. For example, one medicine record described the tablet as 'blister pack'.”
record keeping
3 findings
moderate“For some audits, the registered manager explained what was reviewed, but they failed to record what was checked, what was found and what actions had been taken.”
moderate“there was no record of what was included in these audits. We raised this with the registered manager who agreed to implement an improved auditing system.”
moderate“A staff member told us they had people's risk assessment documents in their car and were due to update them. This meant people's personal information was not stored securely.”
staff competency
3 findings
moderate“Some people still felt staff were not always confident or competent in manual handling techniques and supporting people to move safely.”
moderate“When they started I had to show staff how to use the banana board – not trained in using one at all. Never seen one.”
critical“references were not from previous employers, and there were gaps in staffs' work history... staff were working with people without the necessary checks.”
complaints handling
2 findings
moderate“Two people told us they felt uncomfortable about raising concerns, as they were worried about how this would impact on their care.”
moderate“not all people spoken with had confidence in the complaints process as some of their concerns about staff practice continued”
safeguarding
2 findings
moderate“staff did not always understand the local authority safeguarding procedures. This meant they did not have the knowledge or information to escalate matters externally”
critical“there was an allegation of abuse against a member of staff; the registered manager had allowed the member of staff to remain at work without putting in adequate measures to safeguard people.”
cultural competency
2 findings
minor“complaints they made about staff practice continued. This included staff speaking in their own language during personal care”
minor“one person was practicing a religion that could require a specialist diet... Their care plan did not tell staff about the person's dietary preferences and if they followed a religious diet.”
incident learning
1 finding
moderate“The provider's falls and incidents records were not always analysed for any emerging trends or patterns.”
missed or late visits
1 finding
critical“System in place to monitor late and missed calls were not robust... not all of these calls were documented. One person said, 'They missed my dinner time call [so I didn't get any dinner].'”
staff training
1 finding
critical“26 of the 32 staff members had been employed for more than 12 weeks and should have completed all their training but none of them had.”
supervision appraisal
1 finding
moderate“I've not had a supervision. I didn't have an induction, I haven't had anything. I had a handover from [staff] that's all I got.”
person centred care
1 finding
moderate“People's wishes, and goals were not considered in their care plans or discussed with people.”
leadership
1 finding
moderate“Some staff, people and relatives told us they did not know who the registered manager or deputy manager were.”
end of life care
1 finding
minor“There was no evidence in people's care plans that end of life had been discussed.”