critical“Care plans were not in place to ensure safe and consistent care...Information was not available to guide staff to provide safe care or to recognise and act upon changes in people's health and wellbeing.”
critical“Three people had been provided with high-risk and inappropriate food to meet their assessed needs. This increased their risk of choking.”
medication management
2 findings
critical“Medicine care plans were not in place and there was a failure to provide guidance to staff about people's medicines...lack of information relating to risk management and protocols for administering 'as and when required' (PRN) medicines.”
critical“The person had consistently been administered their medicines outside of the prescribed times, on two occasions over an hour later.”
safeguarding
2 findings
critical“Some staff we spoke with failed to demonstrate an understanding of the signs and types of abuse or their responsibilities within safeguarding processes.”
critical“The provider and staff lacked understanding about their responsibilities to keep people safe from harm and abuse.”
incident learning
2 findings
critical“The provider did not have a robust system in place to monitor or analyse incident records for trends. Information was not used to mitigate the risk of a repeated incident or accident.”
critical“Lessons had not always been learned. Similar concerns found at the previous inspection were also found at this inspection, yet had not been identified by the registered manager or provider.”
governance
2 findings
critical“There was a shortfall in their oversight and governance of the service and a continued failure to implement robust quality assurance processes to improve the quality and safety of the service.”
critical“There were a lack of systems to ensure sufficient oversight of people's care. Neither the provider nor the registered manager had a system in place to enable them to oversee people's day to day support.”
record keeping
2 findings
critical“Records and documents were not available on paper or any other electronic device...Information relating to people's care and the running of the business were not held securely.”
moderate“Records were not always stored securely or well-maintained to demonstrate the care people had received.”
leadership
2 findings
critical“The registered manager did not have day to day oversight of, and access to, electronic records relating to people's care or the management and governance of the service.”
critical“there were wide-spread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
staff competency
2 findings
moderate“The office manager did not have a background in care and was unable to demonstrate they had undertaken any care-based training including safeguarding and medicines.”
critical“Staff had received on-line training in medicines administration and moving and positioning, yet their practical skills and competence had not been assessed.”
supervision appraisal
1 finding
moderate“Staff told us they did not receive formal recorded supervision on a regular basis. Care staff told us they had limited engagement with the registered manager.”
consent capacity
1 finding
moderate“We were not assured by the providers processes to consider people's capacity under the MCA...Some staff we spoke with had limited understanding of MCA.”
infection control
1 finding
moderate“Staff and people told us staff rarely wore face coverings when supporting personal care. This placed people and staff at an increased risk of contracting and spreading Covid-19 and other infections.”
staff training
1 finding
critical“Staff had not been trained and lacked understanding about how to support people who required texture-modified diets and this exposed people to a risk of harm.”
staffing levels
1 finding
moderate“There were not enough staff who had appropriate understanding and skills to meet people's specific needs.”