critical“Their last audit dated May 2023 recorded 'all staff files are up to date', which we found they were not.”
critical“The registered provider and registered manager had not always effectively assessed, monitored or improved the quality and safety of the services provided.”
moderate“Checks on people's medicine administration records (MARs) completed by the registered manager had not identified shortfalls we found related to medicines administered through transdermal (skin) patches.”
minor“The registered manager's directives and reminders to staff had not always had the desired outcome...feedback demonstrated this remained an area for improvement.”
record keeping
2 findings
critical
“1 person was dependent on staff for all their hydration and nutritional needs but ate and drank very small amounts. This person had no risk management plan.”
moderate“The training matrix did not record the actual dates training had been completed by staff, but only the date when topics were next due.”
communication with families
2 findings
minor“Not everyone knew they could request access to the electronic 'app' for their care plan. One relative told us, 'I didn't know I could have access.'”
minor“A few told us they had not always received a call to inform them of a late care call.”
medication management
2 findings
critical“Transdermal (skin) patch medicines were not always applied to people's skin in line with the manufacturer's directions for safe use.”
moderate“Body maps were not in place where people had transdermal patch medicines...the recording system in place was ineffective in ensuring safe practices were followed.”
care planning
1 finding
critical“We found no detailed guidance to inform staff how to safely attach a hoist sling for 1 person who used a hoist for transfers.”
safeguarding
1 finding
critical“We found no investigation record related to a specific allegation and no actions to put safeguards in place.”
staffing levels
1 finding
moderate“Some staff told us that they did not have time to take a break to eat or drink between their morning care calls and starting their lunchtime care calls.”
staff training
1 finding
critical“One staff member told us, 'I support a person with a learning disability but have not done training in this.'”
staff competency
1 finding
critical“The provider's moving and handling trainer had not ensured staff were always taught how to safely use equipment in people's own homes.”
supervision appraisal
1 finding
moderate“Checks on staff's skills took place... they might not have their competency assessed whilst supporting a person in their home until 3 months later.”
complaints handling
1 finding
moderate“Numerous people and relatives shared examples of feeling they were not listened to by the registered manager or senior care staff and their concerns were not resolved.”
person centred care
1 finding
minor“One person, who did not have a catheter, had detailed information for staff to follow about caring for a catheter.”
incident learning
1 finding
critical“The registered manager confirmed they had been made aware of this 4 days prior to our inspection. However, the registered manager confirmed they had taken no action to investigate.”
leadership
1 finding
moderate“In the absence of the registered manager, there was no staff member with delegated responsibility in the office to deputise for them.”
infection control
1 finding
moderate“Staff did not always follow directions given to them by the registered manager about infection prevention and the use of personal protective equipment (PPE).”