moderate“Care plans continued to lack information about the support people needed and their preferences. Medicines related documents were completed correctly, however medicines care plans required improvement.”
critical“Care plans and risk assessments were not comprehensive and lacked detail about people's care and health needs.”
medication management
2 findings
critical“The provider did not have risk assessments for people prescribed anticoagulant medicines. People's preferred method of taking their medicine, support required or confirmation of their level of compliance was not always recorded.”
critical“7 staff members had not completed mandatory medication training. The registered manager and field care supervisor told us, competency assessments for medicine administration had never been completed.”
governance
2 findings
critical“The provider did not have systems to review electronic call monitoring (ECM) records... 17% of calls were late.”
critical“The provider did not undertake robust auditing of the systems and governance across the service. Therefore, they had not highlighted the shortfalls we identified.”
record keeping
2 findings
moderate“Oversight of care records had failed to identify that some care plans did not contain enough detail... no guidance or detail for staff as to what the person's target blood sugar range should be.”
critical“The provider failed to identify 10 staff members to the inspection team. The provider was unable to provide any recruitment records for 6 of these staff members.”
safeguarding
2 findings
critical“Staff performed restrictive practises without the authority or guidance to do so.”
critical“During the inspection, an incident occurred. The provider had failed to record the incident or report it to the relevant agencies.”
complaints handling
2 findings
minor“There was no evidence or record of the response given to the complainant to ensure it had been responded to satisfactorily.”
moderate“There was no evidence to show complaints had been analysed for themes or trends, to enable preventative work, or service improvements to be identified.”
consent capacity
2 findings
moderate“The questions asked as part of the assessment were not recorded to provide clear evidence about whether the person had capacity or not.”
critical“Mental capacity assessments had not been completed by the provider to determine people's ability to make particular decisions.”
person centred care
2 findings
moderate“The provider failed to ensure staff had full access to people's care records. There was no system in place to identify whether records were present at the person's home.”
moderate“People did not always have person-centred care plans in place to guide staff and ensure they received personalised care.”
staff training
1 finding
critical“Staff training records showed not all staff had completed the full mandatory training modules before carrying out care calls.”
staff competency
1 finding
critical“The provider had failed to assess the effectiveness of the training given to staff. For example, competency assessments had not been completed for any staff member.”
incident learning
1 finding
moderate“There were no formal records documenting trends and patterns of incidents or how lessons learned were used to reduce risk or improve services.”
end of life care
1 finding
moderate“Care plans we reviewed contained vague references to funeral arrangements under the section 'end of life wishes'. This meant people's wishes and preferences may not be met.”
communication with families
1 finding
moderate“Several relatives told us there has been ongoing problems with language barriers, and people are not consistently supported by familiar care staff.”
infection control
1 finding
moderate“The provider was unable to evidence all staff had completed training in infection prevention and control (IPC). This posed a risk in relation to managing and minimising the risk of infection.”
leadership
1 finding
critical“The registered manager did not have an adequate understanding of their role, regulatory requirements and lacked oversight of the service.”
missed or late visits
1 finding
moderate“I asked for specific call times, but [Care Staff] come when it suits them. I can't rely on [Care Staff] for medication as they turn up at odd times.”