critical“The provider's care call monitoring data showed a high number of calls where staff were late to arrive... there was not a sufficient number of staff to safely cover all the care calls.”
safeguarding
1 finding
critical“The provider had not identified this issue and only became aware of it when we raised it with them. This had put the child at risk of potential abuse.”
medication management
1 finding
critical“The provider did not use a Medicines Administration Record (MAR) chart when staff applied creams to people's skin... put the person at potential risk of harm.”
care planning
1 finding
critical“People's care, treatment and support plans did not reflect their range of needs... no specific risk assessments in place for people.”
governance
1 finding
critical“The provider had not carried out any audits of the service other than accident and incident audits... The provider had not identified any of the issues we found during our inspection.”
leadership
1 finding
critical“The registered manager did not know how many people the service was supporting. They told us the service was providing care to 25 people. However... at least 52 people received care.”
staff training
1 finding
critical“Staff had not received training in learning disability and autism... Some staff told us they had not done any safeguarding refresher training.”
record keeping
1 finding
moderate“The provider did not have evidence of the legal authorisation giving families the power to make decisions about their relatives' care.”
person centred care
1 finding
moderate“People's needs assessments and care plans did not contain sufficient personalised or person-centred information... mainly about what tasks staff needed to carry out.”
communication with families
1 finding
moderate“People frequently received late care calls and the provider did not always contact people to let them know their care call would be late.”
missed or late visits
1 finding
moderate“One service user told us their care call was due at 08:00 and they often had to wait until after 10:00 before the care worker arrived.”
staff competency
1 finding
moderate“Not all staff understood how to protect people from poor care and abuse and the provider lacked knowledge of how to work with other agencies to do so.”
consent capacity
1 finding
moderate“The provider did not have evidence of the legal authorisation giving families the power to make decisions about their relatives' care.”
incident learning
1 finding
moderate“The provider told us they mainly dealt with issues in isolation, on an individual basis. This meant there was no systematic way for the provider to monitor the service.”