critical“Staff were not always given enough travel time in between calls...On occasions when staff were late the person waiting was not made aware of this.”
staff training
1 finding
critical“Staff did not have training on the Mental Capacity Act (MCA).”
medication management
1 finding
critical“People's care plans did not detail how to support them with their medicines...There were no records available to inform staff about the medicines' side effects.”
care planning
1 finding
critical
“Risk assessments did not have detailed personalised guidance and strategies for staff to follow to help monitor, manage, and minimise risks.”
governance
1 finding
critical“The provider had not implemented their quality assurance and management policy. Their quality assurance systems did not identify concerns we found on this inspection.”
supervision appraisal
1 finding
critical“We found no records of staff supervision from the files we sampled. So, it was unclear how the provider was assured that staff were receiving the support they needed.”
consent capacity
1 finding
critical“Some people's relatives were making decisions on their relative's behalf without the legal authority to do so. Managers understanding of power of attorney and court of protection was not sufficient.”
record keeping
1 finding
critical“Some staff files sampled did not include details of a full employment history, so gaps in employment had not been explained and risk assessed.”
incident learning
1 finding
moderate“Incidents and accidents were recorded, however there were not always checks after the events therefore lessons were not learnt how to avoid events happening again.”
person centred care
1 finding
moderate“People's diverse needs, including religion, culture, and language, were not assessed as part of the care planning process.”
communication with families
1 finding
moderate“Relatives gave mixed views about being involved in assessing their family member's care, some said they were able to contribute, whereas others said they had not had an opportunity.”
cultural competency
1 finding
moderate“People's communication care plans did not include information around their first or preferred language. Staff were not matched to meet people's communication needs or preferred language.”
missed or late visits
1 finding
moderate“They can be up to two hours late and no one says when they are coming or who, if [relative] rings up it's 'someone will be there'.”
staff competency
1 finding
moderate“Staff had received training but did not have a good understanding of best practice models of care. This meant people did not always receive tailored support.”
end of life care
1 finding
minor“People's end of life care wishes were not identified as part of their care plan...the care plans did not include any information on how the person wanted this care provided.”