critical“Allegations of abuse had not been recognised as reportable and were not investigated... As part of this inspection we raised eleven safeguarding concerns with the relevant local authorities.”
missed or late visits
1 finding
critical“Yes, many times they have not turned up and many times they have been late.”
medication management
1 finding
critical“Gaps were seen in the recording on MARs making it difficult to establish whether people had received their medicines.”
care planning
1 finding
critical“Risk assessments were either missing, or where available, lacked detail or contained general statements.”
staff training
1 finding
critical“Staff were routinely asked to give care and support for people with specific health needs which they were not trained to provide.”
staffing levels
1 finding
critical“Staffing levels were not sufficient to meet people's needs as people, relatives and records we saw showed missed and delayed calls on a regular basis.”
supervision appraisal
1 finding
moderate“We saw some evidence of staff supervision, although staff told us they had not received this support.”
consent capacity
1 finding
critical“There was no assessment of capacity and record of best interest's decisions in these cases.”
person centred care
1 finding
critical“Individual care plans we looked at were task focused and there was little information about individual risks, goals, skills and abilities.”
end of life care
1 finding
critical“Care plans we looked at did not contain an assessment of people's end of life wishes to ensure their preferences were met during this important stage of their life.”
communication with families
1 finding
moderate“There was insufficient evidence to demonstrate that the service had identified people's communication needs.”
complaints handling
1 finding
moderate“On the third day of our inspection, we saw this was not recorded in the complaints log.”
governance
1 finding
critical“There were no systems in place to assess, monitor and improve the quality and safety of the service provided.”
leadership
1 finding
critical“Management oversight over key aspects of the service was not evident. Recruitment, rota management, person-centred care and management of risk were poorly managed.”
incident learning
1 finding
moderate“Records of accidents and incidents were maintained, but these were not used to inform and update people's risk assessments.”
record keeping
1 finding
moderate“We looked at daily notes for one person and found a week of recording was missing from June 2019.”
staff competency
1 finding
critical“The staff training matrix showed that only three out of 17 staff had their competency to administer medication checked.”
cultural competency
1 finding
moderate“Where people had specific requirements relating to their religious or cultural needs, this was not recorded in their care plan.”
other
1 finding
critical“Recruitment procedures did not protect people from the risk of unsuitable staff being employed. One staff member's file showed they did not have a new DBS check when they joined the service.”