critical“a person's risk management plans stated they required 2 staff to support them to mobilise safely, but the registered manager informed us this care was only in January 2023.”
moderate“Some people's care plans had not been updated to provide personalised information about their preferences for how they liked to be supported.”
minor“a person's plan did not include guidance on how to recognise if they were becoming unwell due to their identified health condition.”
critical“there was no assessment in the person's risk management plans of how the risks associated with these conditions affected them.”
person centred care
3 findings
critical
“Some people's care plans did not always provide appropriately detailed information about the care or support they required.”
moderate“One person's care plan stated they needed support with bathing and dressing but there was no information about their bathing or personal grooming preferences.”
moderate“The only criticism I've got is they wash me down as if I'm in a car wash. They're very firm but ease back if I tell them.”
governance
3 findings
critical“this system of checks had not been consistently effective as it had not identified and addressed the issues we found during this inspection.”
critical“The registered person did not always effectively operate systems and processes to assess, monitor and improve the quality of the service and to assess, monitor and mitigate risk”
critical“this system of checks had not been consistently effective as it had not identified and addressed the issues we found during this inspection.”
missed or late visits
3 findings
moderate“a relative said, 'There have been occasions when the staff are running very late and we don't know if they will be coming and I have had to phone … They don't always let us know'”
minor“the provider still did not have a formal system for recording and reviewing missed or late care visits to identify and reduce the frequency of these”
moderate“Most people and relatives told us they experienced late or variable care visits.”
communication with families
2 findings
moderate“a person's plan noted they were hard of hearing, wore spectacles and 'slightly blind' in one eye, but in order to meet their communication needs only stated, 'Care workers will visit me 4 times a day'”
moderate“One person's care plan stated they were hearing impaired and used hearing aids. However, there continued to be no direction in the plan for staff on making sure the person wore their aids or how best to communicate with the person.”
record keeping
2 findings
moderate“Records of another person's care plan review in February 2023 stated the person was 'bed-bound' with no mobility equipment in place, while also noting they needed support to mobilise with a walking frame.”
moderate“some of the records we saw were not always clear and legible about what care was provided.”
staff competency
2 findings
minor“the provider noted that some of these assessments were overdue as a result of managing the service through the COVID-19 pandemic.”
critical“the provider had not recorded obtaining or seeking to obtain any references from the applicant's previous employers.”
end of life care
1 finding
moderate“the registered manager stated staff had offered to discuss this with some people but we still found there was no record kept of this.”
medication management
1 finding
critical“there was no information about what medicines staff helped the person to take and no medicines administration records (MARs) to show that staff had supported the person to take them as prescribed.”
incident learning
1 finding
moderate“the manager reported they had not considered reviewing the person's risk management plans in response to these incidents to consider if their care needs had changed.”
infection control
1 finding
moderate“The provider had not completed COVID-19 risk assessments for all the people whose care records we saw.”
complaints handling
1 finding
minor“I'm not so sure if I'd recommend the company due to the way they dealt with my complaint.”