critical“Alliance Care Ltd staff were investigating safeguarding concerns without the oversight and review of the registered manager. As a result, people were exposed to the potential of ongoing harm.”
critical“1 serious allegation of abuse was not fully investigated for several months. This exposed service users to the risk of ongoing harm.”
medication management
1 finding
critical“People's medicine administration records (MAR) showed multiple discrepancies, including doses of medicines being administered at short intervals or double doses recorded.”
care planning
1 finding
critical
“People who received nutrition and hydration via PEG, did not have care plans in place to guide staff about their needs.”
staff training
1 finding
critical“Only approximately a third of the staff team had received training in the 12 months prior to the inspection, in subjects such as medication administration, moving and handling or infection control.”
staff competency
1 finding
critical“There was no system in place to review how staff managed key risks such as medication administration or moving and handling.”
incident learning
1 finding
critical“The provider failed to review accidents, incidents and safeguarding matters for the purpose of maintaining oversight and identifying any learning for the organisation.”
governance
1 finding
critical“Quality assurance systems had failed to identify the areas of concern we highlighted during our inspection. Audits had not been effective in finding the issues we established.”
missed or late visits
1 finding
moderate“Another person told us, 'I pay for 30 minutes and they stay for 10. Sometimes they don't turn up at all and I still have to pay for the call.'”
person centred care
1 finding
moderate“Care plans did not always detail people's needs, wishes and goals. 1 person had a desire to work towards greater independence. However, there was no guidance on how care staff could support this.”
record keeping
1 finding
moderate“1 person's care plan stated they had epilepsy, when this wasn't the case. Care plans contained minimal information about people's communication needs.”
consent capacity
1 finding
moderate“Care plans did not consider people's capacity to consent to care. We did not find evidence of capacity being assessed for specific decisions.”
supervision appraisal
1 finding
moderate“The provider had failed to review staff skills and competence. While spot checks were undertaken to observe some aspects of staff practice, there was no system in place to review key risks.”
infection control
1 finding
minor“Many staff had not received recent infection control training. However, spot checks showed staff had a sound understanding of good infection control measures.”