critical“people's care visits were significantly shorter than the agreed duration, with many only lasting half of the allocated time.”
moderate“the service did not have robust systems in place to monitor missed and late visits in real time.”
governance
2 findings
critical“The provider had not ensured effective processes were in place to monitor and improve the safety and quality of the service. This was a breach of Regulation 17”
critical“These checks had not identified all the shortfalls we found at this inspection. For example, the management of risk, complaints review and analysis.”
incident learning
2 findings
critical“where the provider had identified people with shortened care visits in June 2022, we found the some of the same people were still receiving shortened visits in November 2023.”
critical“The management team did not recognise that by not using the lap strap this left the person at risk and they had not taken any additional action to mitigate the risk of harm.”
care planning
2 findings
moderate“some risk assessments lacked detailed guidance about what the specific risks were and how to keep people safe.”
critical“We found one person who had started using the service the week prior to our visit did not have a care plan in place.”
end of life care
2 findings
minor“There was no information within care plans which would provide guidance as to people's assessed wishes at the end of life or if they needed palliative care.”
minor“Documents to record the arrangements, choice and wishes people may have for the end of their life were not in place to ensure peoples final wishes were met.”
record keeping
2 findings
moderate“'Staff must limit the amount of detail they write in care records e.g. don't detail what was eaten just that the person ate well.' This is contrary to recognised good practice guidance.”
minor“People's capacity was assessed by the service in line with the MCA 2005. However, the service did not formally record this or discussions they had with people.”
staffing levels
1 finding
moderate“The provider had not always ensured there were sufficient numbers of staff available to meet people's needs in a timely way.”
leadership
1 finding
moderate“The service did not have a registered manager in post at the time of the inspection and there had been several changes in management oversight and structure since our last inspection.”
person centred care
1 finding
minor“where people had raised issues during their monthly telephone reviews, the provider had sometimes written 'no action required' in response.”
safeguarding
1 finding
critical“None of the staff we spoke with were able to demonstrate an understanding of local safeguarding protocols and some were unable to understand what we were asking due to their limited command of the English language.”
staff competency
1 finding
critical“Safety checks had not always been carried out prior to staff started working unsupervised. We found two staff members where the provider had not obtained character references.”
medication management
1 finding
moderate“Where people were prescribed topical medicines such as creams and lotions there was no body map in place and no support plan instructing staff as to where to apply the prescribed medicine.”
consent capacity
1 finding
critical“The management team lacked knowledge of their regulatory roles and responsibilities in relation to the Mental Capacity Act 2015 (MCA) and associated Deprivation of Liberty Safeguards (DoLS).”
staff training
1 finding
critical“Staff had not always received the quality and range of training they required to meet people's needs and equip them for the role they were employed to perform.”
complaints handling
1 finding
moderate“15 complaints had been received since April 2018...there was no overview of the complaints that had been received to ensure that these could be analysed to identify any themes or trends.”
supervision appraisal
1 finding
moderate“Where spot checks had identified areas for improvement, there was no follow up action evidenced to ensure that the staff member improved these areas.”
cultural competency
1 finding
moderate“Staff where their first language was not English did not always understand their needs... 'lines get crossed, this can be very tiring.'”