moderate“whilst supervisions and training were taking place, records used for the oversight of these areas lacked structure or were too informal.”
critical“The nominated individual had not maintained oversight of the service and was unaware of the concerns we raised during the inspection.”
record keeping
2 findings
moderate“Some record keeping was unstructured and informal.”
moderate“Staff told us they didn't always have access to the information, or the information available via their mobile devices was limited. 'The care plans need updating.'”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post. The nominated individual had previously stepped back from the day to day running of the service.”
critical“The nominated individual did not demonstrate an understanding of the duty of candour. Concerns identified during the inspection were dismissed, with a culture of blaming former employees.”
staff training
2 findings
moderate“At the last inspection, records showed not all staff had received the mandatory training needed to guide staff on how to support people safely and assess potential risks.”
critical“Not all staff had received adequate training in moving and handling, safeguarding, or medication administration, this placed people at risk of harm from improper or unsafe practices.”
incident learning
1 finding
minor“We identified some records were not always structured or clear.”
medication management
1 finding
critical“Staff supporting people with their medicines without adequate training placed people at risk of harm... staff told us they had been working and administering medicines without being trained.”
staff competency
1 finding
critical“The provider told us all staff had been competency assessed as safe to administer medicines. However, when speaking with staff, many confirmed they had not been assessed for medicines, or spot checks.”
safeguarding
1 finding
critical“Not all staff had received adequate training in safeguarding, including how to spot the signs of potential abuse. A staff member told us, 'I can't remember if I did safeguarding training.'”
missed or late visits
1 finding
moderate“On the weekend they come very late. One time it was 1 o'clock, another time it was 11 o'clock to help me wash and dress. When my family came at the weekend I was still in my nightdress.”
communication with families
1 finding
moderate“People and relatives stated they were not informed when people were running late... A person told us, 'There is no knowledge of timings or a rota. They refuse to tell you who is coming.'”
person centred care
1 finding
moderate“People told us they had not been asked for their views or feedback... 'I've never actually seen a care plan. I assume there must be one somewhere.'”