critical“16 out of 300 plans had been revised. At this rate of progress, care plans would not be completed within the timescale set.”
critical“a person with epilepsy was having a bath call, no reference had been made to the risk to the person in the event that they suffered a seizure whilst bathing.”
safeguarding
2 findings
critical“A safeguarding vulnerable adults action plan had been generated... 10 actions assigned to 121 Care & Mobility Ltd and at the time of the inspection none had been added to the care plan.”
moderate“Another member of staff told us they had now reported a safeguarding issue twice because they had received no feedback from office staff as to what action had been taken.”
record keeping
2 findings
critical“Care plan stated 'X has become doubly incontinent since the last assessment'. Then later it stated 'X goes to the toilet independently'. No further guidance for staff.”
moderate“Audits of care records had not identified where there were gaps in risk information.”
governance
2 findings
critical“One person's MAR sheet audit dated 06 April 2018 stated 'No further action required' but had failed to identify errors made by staff in the administration of medicines.”
critical“Audits and systems were in place to monitor the quality of care people received but these had not always been effective in identifying shortfalls in people's care.”
incident learning
2 findings
critical“Actions taken had failed to demonstrate organisational learning by addressing the underlying issues, potentially leaving people at further risk of harm.”
minor“People who said they had completed surveys in the past said they had never received feedback regarding whether specific comments they had made or learned how theirs and other peoples comments were helping to shape the development of the service.”
communication with families
2 findings
minor“Two staff discussing the reasons for the delay across the front garden boundary fence... did not seem to be concerned that the visit was on public display where sensitive information could be overheard.”
moderate“many said they were often not told about changes to their times or carers. When they rang the office and left messages staff rarely rang them back.”
leadership
2 findings
critical“The provider and registered manager had not managed risk or made changes at a systemic, rather than reactive level.”
moderate“The registered manager was unaware of some of the issues people had raised with us and this made her aware of how with the expansion of the service her role had changed.”
medication management
1 finding
critical“We saw a carer apply a daily patch to the persons shoulder... 'We put the patch on for (husband) as it's too fiddly, but there's no MAR chart.'”
consent capacity
1 finding
critical“We spoke to one senior staff member about completing capacity assessments and were told that staff would not do them and that they would need a doctor to complete an MCA assessment.”
staff training
1 finding
critical“'The two who were here two Saturdays ago didn't know what to do. The slings were put outside the arms instead of inside... they said they hadn't been trained to use one.'”
staff competency
1 finding
moderate“One relative said carers seemed 'Thrown in at the deep end'. One girl said, 'I sat in a classroom for a few days and now I'm out on a call'.”
person centred care
1 finding
moderate“Care plans contained basic information about care and support tasks. There was little additional detail about people's lives, protected characteristics, interests or personal histories.”
end of life care
1 finding
moderate“No mention of end of life care, reference to a life limiting medical condition or any reflection of the person's religious practices or cultural considerations.”
infection control
1 finding
moderate“Person's needs had changed and support increased to include meal provision. However, risk assessments and care plans had not been updated and staff were using the soiled kitchen.”
cultural competency
1 finding
moderate“People's sexuality, religion or cultural support needs were not recorded as part of their assessment; this left them at risk of discrimination.”
supervision appraisal
1 finding
moderate“supervisions had not picked up or addressed staff feelings of being unsupported.”