critical“A significant safeguarding concern was not handled in a safe way. A referral to the local authority should have been made...but this did not happen.”
governance
1 finding
critical“Regulation 17 HSCA RA Regulations 2014 Good governance...We issued a warning notice to the provider giving them a timescale to be compliant.”
incident learning
1 finding
critical“When people and relatives raised issues about staff practices, staff were just removed from that person's rota with no investigation to learn lessons.”
care planning
1 finding
moderate“People did not have up to date risk assessments. When health needs changed people did not have revised risk assessments and care plans.”
infection control
1 finding
moderate“People told us staff did not always use PPE when they should have. They gave examples of staff not wearing aprons when they supported people to have a wash.”
missed or late visits
1 finding
moderate“Some people told us they had experienced late and missed care visits. The providers electronic system...did not support this view, but some people were very clear about this.”
staff training
1 finding
moderate“The registered manager and management had not received training for some years relevant to key aspects of their work. Such as safeguarding, writing good risk assessments and...MCA.”
staff competency
1 finding
moderate“New staff who did not speak English well, they needed more support to understand their role and the people they were supporting.”
consent capacity
1 finding
moderate“The registered manager and management...had not understood the principles of the MCA when people had appointed a relative to make decisions on their behalf.”
complaints handling
1 finding
moderate“Relatives told us they did not hear back from the office when they raised issues. Nor were they given the opportunity to make a formal complaint.”
end of life care
1 finding
minor“The registered manager and management were not considering this aspect of people's lives unless they were actively at the end stage of their lives.”
person centred care
1 finding
minor“Information about people's lives, interests and what was important to them was limited and not explored.”
communication with families
1 finding
minor“There was a lack of effective engagement with people and their relatives to seek their views.”
cultural competency
1 finding
minor“There were missed opportunities to make some people's care plans accessible to them if they did not speak English.”