critical“one person's care plan referred to the use of a hoist, but the risks associated with its use had not been assessed and there was no guidance for staff on how to use it.”
critical“One person's care plan contained contradictory information. The care plan stated the person was unable to walk or weight bear but also instructed staff to prompt the person to use equipment when walking.”
governance
2 findings
moderate“Audits of care records were taking place on a monthly basis, but they failed to identify the issues we found with risk assessments at this inspection.”
critical“Systems to assess, monitor and improve the service were not sufficiently robust and management oversight was not evident over key aspects of the service.”
staffing levels
2 findings
moderate“staff told us they worked long hours, and breaks and travel time were not accounted for.”
critical“One relative told us their relative had 27 different care staff within a 13-day period. A member of staff said, 'Clients have no consistency of care.'”
leadership
2 findings
moderate“The office [staff] just changes the rota whenever they feel like it and don't ask. Morale is quite low.”
moderate“One member of staff told us, 'I don't feel supported. I can only get in touch with the office if I put my number as withheld. They won't answer if they know it's a carer ringing.'”
missed or late visits
1 finding
critical“'The carers should have been on site at 9am but hadn't turned up until 11.30am' and 'The staff I cannot fault. It's the times that are the problem.'”
record keeping
1 finding
moderate“Some care plans had not been scanned correctly onto the electronic system and sentences recorded on the top and bottom of pages were missing.”
medication management
1 finding
moderate“A second member of staff told us, 'There was no training with Lotus. Just training on dosette boxes and how to check it.'”
safeguarding
1 finding
moderate“Another member of staff said, 'We have to go to the office normally to raise one. I didn't know we can just raise them ourselves; it's office staff who do that.'”
incident learning
1 finding
moderate“The registered manager told us lessons learnt were shared with staff via staff meetings. However, the agendas and minutes of staff meetings we looked at did not record any of these conversations.”
infection control
1 finding
moderate“'I am not happy with [staff]. They are not wearing masks properly; it doesn't cover their noses and they don't wear aprons.'”
consent capacity
1 finding
moderate“We saw a best interest's assessment had been completed for each person [assessed as having capacity]. This is not in line with the requirements of the Act.”
person centred care
1 finding
moderate“The planning of people's care was not person-centred, up-to-date or reflective of their changing needs or concerns.”
communication with families
1 finding
moderate“A relative said, 'We've complained loads of times… don't hear anything.' One person told us, 'It's like talking to a brick wall'.”