critical“The provider did not follow safe recruitment processes to ensure staff were suitable to work with people with health and social care needs.”
critical“Staff were carrying out a procedure with specialised equipment without training or relevant guidelines in place.”
care planning
2 findings
critical“Care plans did not contain information about the risk of low blood sugar (hypoglycaemia) or what signs or symptoms might indicate people were experiencing low blood sugar”
critical“Risk assessments for people at risk of developing pressure sores did not include all the known risks.”
medication management
2 findings
critical“The failure to ensure the safe management of people's medicines was a continued breach of regulation 12”
critical“One person's MAR which had been signed by staff was missing the names, dosage and instructions of the medication so it was impossible to know what medication the staff had administered.”
staff training
2 findings
moderate“The training matrix also showed staff had not received diabetes training.”
critical“Not one of the care team can use the suction machine properly... they put the machine on but do not attach it, so it sounds like it is working but it isn't”
missed or late visits
2 findings
moderate“The carers are never on time and I am always waiting.”
moderate“They don't always arrive on time... Time keeping, I have told them, it was ok for a week, then back to bad”
governance
2 findings
critical“the provider was failing to assess, monitor and improve the quality and safety of the service effectively”
critical“Quality audits supplied during the inspection did not identify all the issues we found with medicines, risk management, record keeping and adherence to the Mental Capacity Act 2005.”
leadership
2 findings
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
critical“There is total chaos... The organising of the carers is due to poor management.”
record keeping
2 findings
moderate“We saw one safeguarding investigation report which contained numerous typographical errors which made the document indecipherable in places.”
critical“Fire risk assessments produced after we shared our concerns were backdated, in some cases to more than 12 months before they were written.”
complaints handling
1 finding
minor“letters to people who had cause to complain were not clear and did not adequately explain what had gone wrong.”
supervision appraisal
1 finding
moderate“50% of respondents said they did not feel supported by their line manager, did not feel able to contribute to improvements and been subjected to bullying or harassment at work.”
safeguarding
1 finding
critical“The authority had investigated and substantiated an allegation that one person was left without care during August and September.”
consent capacity
1 finding
critical“The service was not adhering to MCA guidelines. Mental capacity assessments were not always carried out when the provider had cause to suspect people did not have capacity to consent to their care.”
staffing levels
1 finding
moderate“I have had 22 different carers... Staff do chop and change... No, I have a lot of different carers”
infection control
1 finding
moderate“Staff were not carrying out weekly COVID-19 tests according to current government guidelines.”
person centred care
1 finding
moderate“Care logs we reviewed did not always show evidence of person-centred care. Some care logs contained undignified language when referring to incontinence aids.”
communication with families
1 finding
moderate“No, I am not listened to, sometimes not at all.”
other
1 finding
critical“We could not be assured that all staff had been recruited safely as records showed there were many more staff working who were not included in the provider's list of safely recruited staff.”