moderate“A care plan we reviewed for a person at risk of choking was found to be lacking in detail to ensure this risk was fully minimised.”
moderate“Another care plan we reviewed stated a person was at risk of falls, however the risk assessment required greater detail to ensure this risk was fully reduced.”
critical“a person who lived with chronic obstructive pulmonary disease (COPD) did not have a care plan or risk assessment in place to detail how staff could safely care for them.”
medication management
3 findings
moderate“one care plan we reviewed stated a person had a 'covert certificate in place', however their care plan did not detail how medicines should be given covertly.”
moderate
“we found inconsistencies in recording. For example, we found a small number of gaps on medicine administration records.”
critical“Medicines were not managed safely. Medicine records we reviewed did not contain the required information to ensure people received their prescribed medicines safely.”
record keeping
2 findings
moderate“However, we found some care plans to be unclear.”
critical“Staff files we reviewed did not evidence that all pre-employment checks were being carried out... none of the files we reviewed had two references”
communication with families
1 finding
minor“The communication has really improved but there is still room for improvement in that aspect.”
missed or late visits
1 finding
critical“They arrive late and rush in and rush out, which means they often don't wash my [relative] properly. When they are really late, my [relative] has often been in a wet pad for between 15 to 18 hours.”
staffing levels
1 finding
critical“There were not enough suitably qualified staff to ensure people received care and support which resulted in early, late and missed calls. This placed people at risk of harm.”
staff training
1 finding
critical“no staff had received a supervision in 2022 prior to our inspection and 39% of staff had not completed their training.”
supervision appraisal
1 finding
critical“no staff had received a supervision in 2022 prior to our inspection”
safeguarding
1 finding
critical“Following a safeguarding incident investigated by the local authority not enough action had been taken to ensure the incident was not repeated.”
incident learning
1 finding
critical“Lesson were not always learnt when things went wrong... No investigation had been completed internally by the registered manager”
governance
1 finding
critical“The provider did not utilise quality assurance systems. This meant they did not identify issues to drive service improvement.”
leadership
1 finding
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.”
person centred care
1 finding
moderate“The provider failed to ensure the culture was person centred, open or inclusive. This meant people were at risk of receiving poor care.”
complaints handling
1 finding
moderate“we found a number of questionnaires in care records, all of which had made concerns relating to call time, length of calls and in some staff performance. No action had been taken”
infection control
1 finding
moderate“two people we spoke with told us staff have not worn masks recently and they had to request staff put a mask on.”
staff competency
1 finding
moderate“Recently one staff member walked out on the call because they didn't like how my [relative] was, they have no understanding how dementia effects my [relative].”