critical“The provider was not working within the principles of the MCA. Staff had not always completed MCA assessments for people in line with their policy.”
minor“current assessment tool...did not have a section for field care supervisors or managerial staff to confirm in writing they had been shown an original LPA document”
governance
2 findings
critical“The provider was not always operating effective systems and processes to assess, monitor and improve the quality and safety of the service.”
critical“provider had failed to implement and maintain the use of effectual quality monitoring practices...86 staff had not had a 'spot check' visit by a field care supervisor”
missed or late visits
2 findings
moderate“Our analysis highlighted timekeeping issues, including examples where care workers were not logging calls correctly, being logged into two locations simultaneously and issues with care workers turning up late.”
moderate“some people had experienced disruptions...due to unforeseen changes to staff they were not advised about in advance, late visits, missed visits and visits that felt rushed”
care planning
2 findings
moderate“We found the same information was recorded for six people which stated that they should have 'A low sugar diet, encourage me to have a sugar free diet'... we were not assured that care plans were personalised.”
critical“provider's own analysis indicated there was an 80% compliance with people having a full care plan in place. Care staff were using 'care grid service schedules'...which did not have the necessary level of detail”
complaints handling
2 findings
moderate“Within the file there was no record of the correspondence outcome sent to three people which meant we were not always assured people were told the outcome of their complaint.”
moderate“Not all of these complaints had been resolved within the timescales set...we did not see ongoing evidence of how the former management team used this information to improve the quality”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post... care workers spoke about a culture of favouritism and people felt communication needed to be improved.”
moderate“The service did not have a registered manager. The new manager had been in post for two weeks at the time we commenced the inspection.”
communication with families
1 finding
moderate“People and their relatives felt the office was not well managed due to the attitude of office staff... 'If I ring the office, they are terrible.'”
incident learning
1 finding
minor“A complaint had been made earlier in the year about this issue and no learning had taken place.”
medication management
1 finding
critical“medicines were administered late, due to care staff arriving late...previously there was a lack of managerial scrutiny and auditing in relation to medicine practices”
staff training
1 finding
critical“compliance level for mandatory training was 75%...42 did not have any evidence of having completed the TUPE workbook...72 staff did not have evidence of supervision on file”
supervision appraisal
1 finding
critical“staff did not receive regular one to one support and guidance from their line managers...72 staff did not have evidence of supervision on file”
record keeping
1 finding
moderate“risk assessments had not been undertaken for all people using the service...one care worker informed us they provided personal care for a person with a PEG tube but did not have written information”