critical“multiple safeguarding concerns had not been identified, reported, or actioned robustly. This included people at risk of inappropriate restraint, going missing and police incidents.”
medication management
1 finding
critical“Care plans and risk assessments contained conflicting, inconsistent or no information, to guide staff on the level of medication support people needed. This was unsafe.”
missed or late visits
1 finding
critical“Records showed some people's care calls lasted for less than half of the required time.”
care planning
1 finding
critical“Risk assessments were either not in place or were not sufficiently detailed to help staff provide safe care.”
governance
1 finding
critical“Only 90 of the people using the service had been added to the provider's electronic care planning system which meant the outstanding people were not having their call times monitored.”
staffing levels
1 finding
critical“A single staff member sometimes attended calls for people who required 2 staff to support them safely.”
staff competency
1 finding
moderate“Competency checks of staff skills were not completed. This meant the provider could not be assured staff were safely and effectively applying their learning.”
supervision appraisal
1 finding
moderate“Systems in place to ensure staff received regular and supportive supervisions, were not robust. We nor the provider could be assured these had been regularly completed for all staff.”
incident learning
1 finding
moderate“Due to the lack of analysis of feedback, complaints, compliments, daily records and incidents and accidents, the provider failed to robustly identify, and cascade lessons learnt.”
complaints handling
1 finding
moderate“There had been no complaints recorded since 2015 although we are aware complaints had been raised with the provider.”
consent capacity
1 finding
critical“We had concerns in relation to the registered manager's understanding and application of the MCA. The required principles of the MCA were not consistently applied.”
person centred care
1 finding
moderate“Staff do not help to promote [relative's] independence and help them to achieve goals and aspirations and they get bored.”
record keeping
1 finding
moderate“The provider had failed to provide us with the full and correct details of all people supported by them as their systems and processes to track people using the service were not robust.”
cultural competency
1 finding
moderate“A staff member had not respected their cultural beliefs, which had resulted in the family raising safeguarding concerns.”
infection control
1 finding
minor“The provider could not be assured all staff were following safe practices and were adhering to the correct use and safe disposal of personal protective equipment (PPE).”
staff training
1 finding
moderate“Some staff told us they had not received specific training for people's known health conditions or how to respond when people exhibited distress.”
communication with families
1 finding
moderate“Staff simply do not speak to them and do not appear to understand that the person is able to understand them although they can't communicate with them.”
end of life care
1 finding
minor“The provider told us they had yet to commence work developing people's care plans to ensure people's preferences and choices for their end of life care were acted on.”
leadership
1 finding
critical“The provider told us they could now see, following our inspection, that they had grown too quickly without the correct systems and processes imbedded.”