critical“One person was a known risk of choking and required meals prepared in a specific way. There was no specific care plan in place to guide staff when preparing meals.”
moderate“one person did not have a risk assessments in place in relation to catheter care or how staff managed people's behaviour”
moderate“one person had epilepsy and there was no risk assessment in place for staff to follow should the person have a seizure”
governance
3 findings
critical“The provider failed to implement an audit schedule or quality assurance policy and procedure. There was no monitoring or audits of care call times, medicine administration or people's care plans.”
moderate
“staff told us when they contact the office staff it can take as long as 20-30 minutes for the office staff to return their call”
minor“The registered manager did not have a system to look at care across the service so was not monitoring any patterns which occurred across the service.”
medication management
2 findings
critical“clear written guidance was not always in place for when to offer people medicines which were prescribed on an 'as and when required' basis (PRN medicine).”
minor“information about people's allergies had not been included on the medication administration records for ease of reference in the event of an emergency”
missed or late visits
2 findings
critical“one person told us, '[Care staff] are too late, I need to go to bed.' Another person told us, 'I've had to complain as [care staff] are always late.'”
moderate“some calls was twenty-five minutes away from each other, the five minute travel allowance was not sufficient to ensure people had their call on time”
complaints handling
2 findings
moderate“1 person told us, 'I've complained before, but they don't listen to you.' Another person told us, 'I've complained about the time care staff come but [the provider] doesn't listen to me.'”
minor“We asked the registered manager how they looked for any patterns in people's concerns or complaints. They told us they didn't at the time of our inspection”
record keeping
2 findings
critical“People's risk assessments had not been updated or reviewed following accidents or incidents. One person had a history of falls and had recently fallen in the presence of care staff. No risk assessment or care plan was in place.”
moderate“registered manager told us developments were being made to people care records... more information was needed”
safeguarding
1 finding
critical“care staff were often late which led to their relation experiencing periods of incontinence.”
staffing levels
1 finding
critical“The registered manager had not always allocated enough time between calls to ensure people received timely care. This meant people did not always receive the care they required when needed.”
incident learning
1 finding
critical“when a person fell in the presence of care staff, there was no analysis of the incident or attempts made to mitigate the risk of reoccurrence.”
supervision appraisal
1 finding
moderate“Most staff told us they did not receive regular supervision. One member of staff told us, 'I've not had a supervision since I've been working here.'”
person centred care
1 finding
moderate“Assessments completed for people were basic and did not always incorporate key information, such as their life history, wishes, preferences or protected characteristics.”
leadership
1 finding
moderate“Most care staff we spoke with told us there was a poor culture within the service. Some staff told us they would not recommend working for the provider and were actively looking for a new job.”
communication with families
1 finding
moderate“Care plans included very little information about the persons communication needs reading, '[Person] is unable to communicate.' There was no other information made available to staff.”
staff training
1 finding
minor“one member of staff explained to us how they supported a person who had a very specific health condition; they had not received any training in the specific area”