moderate“one care plan stated that a person was at risk of developing pressure sores. However, there was no risk assessment in place to guide staff to ensure that measures were in place to prevent this happening.”
moderate“when we saw another care plan that noted that the person had an identified risk of pressure sores, there was a no risk assessment in place outlining safety measures”
minor“Care plans had information about people's preferences and their life histories, though did not have a lot of information about their likes and dislikes.”
staff training
3 findings
moderate“not all staff had received training about the operation of the law [MCA]. The home care manager told us that this training had been organised and was due to be provided to staff in the near future.”
moderate
“This did not include relevant subjects such as protection from developing pressure sores, Parkinson's disease, mental health conditions and diabetes.”
moderate“not all staff had been trained in essential issues, such as health and safety, behaviour that challenged the service, moving and handling techniques, first aid”
consent capacity
3 findings
moderate“Staff did not all understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS)”
moderate“We did not see evidence that the provider had relevant procedures in place to assess people's mental capacity”
minor“Care records showed people's capacity to make decisions, though not all mental capacity assessments had been carried out. The office manager said this would be carried out.”
complaints handling
3 findings
minor“The procedure set out that the complainant should contact the service. It was not clear that people could refer complaints to the local authority if they wished.”
minor“some informal complaints did not have evidence of any follow-up action. There was no evidence of a response sent to the complainant”
minor“People had not received a written response to their complaints. The office manager said that this would be carried out in the future.”
governance
3 findings
minor“There were a small number of comments made which needed action, though there was no action plan in place.”
moderate“No evidence was seen that the audit system had identified that a relevant reference was not sought as part of the staff recruitment process”
minor“Quality audits were carried out to drive improvement of the service. Some needed to be more comprehensive to ensure all aspects were audited.”
medication management
2 findings
minor“there were a small number of gaps, which had not been explained in medicine records. The registered manager said this would be followed up, to ensure that people always received their medicine on time.”
moderate“medicines to be taken as needed did not specify the required dose and in what circumstances it could be given”
missed or late visits
2 findings
minor“one person's lunchtime call time was recorded as being from 30 minutes to 60 minutes early on some occasions.”
moderate“we found a small number of instances where people had late calls and had to wait up to over an hour for staff to arrive”
supervision appraisal
2 findings
minor“two staff members said that had been an issue trying to get through to their line managers if they had any queries.”
minor“supervision had not been frequent in the past year”
cultural competency
2 findings
minor“there was no information on people specific wishes in relation to their religious and cultural needs such as how to respect religious artefacts.”
minor“The person was recorded as not being able to speak English fluently. However, there was no evidence that the agency had tried to match this person with a staff member”
record keeping
2 findings
moderate“records did not always show that the necessary documentation for staff was in place to demonstrate they were fit to supply personal care to people”
minor“there were a small number of gaps in medicine administration records. The office manager said this would be followed up with staff.”
safeguarding
1 finding
minor“They did not contain the contact details of all relevant agencies where staff could report their concerns to”