moderate“audits of people's records had not identified the short falls we had found about working in line with the MCA.”
critical“The provider was failing to meet Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
critical“The agency had not informed the Commission about it, which they should have done. The provider had not displayed their most recent performance rating on their website.”
moderate“The training matrix did not include those care workers who started their employment with the agency after June 2016.”
critical“Audits had failed to highlight that there were no detailed plans in place for some risks identified during people's assessment.”
record keeping
4 findings
minor“some people's care plans, this information was limited to stating their religion and ethnicity only, and not their actual needs or how these should be met.”
minor“There were no guidelines for staff to recognise any side effects from the medicines given.”
moderate“Some information about risk to people's health and wellbeing was confusing and did not always match other risk assessment documents in people's files.”
moderate“There were no designated accident/incident forms completed which meant that it was difficult to audit the amount of episodes and what actions the provider had taken.”
consent capacity
3 findings
moderate“two mental capacity assessments to receive care from the provider were partially completed and signed by a family member when this was the responsibility for the staff to complete.”
moderate“the provider had not always ensured relatives had lasting Power of Attorney that gave them the right to make decisions on their family members behalf when they lacked capacity.”
critical“The agency did not always work within the principles of the Mental Capacity Act 2005 (MCA) and there was a risk that decisions related to people's everyday care were not made in their best interest.”
missed or late visits
3 findings
moderate“There are frequent missed calls - I phoned the office - I'm also worried that if anything had happened in the day and they didn't turn up”
moderate“One person told us they frequently had to wait up to 45 minutes for carers to arrive. 'Sunday evening (they should be) at 6 o'clock, they had arrived at 6.45pm'.”
minor“Not great. They don't come at regular times, and don't always call when they are late.”
care planning
3 findings
minor“One person's risk assessment identified them as living with diabetes... no description of the possible concerns that might arise such as complications”
moderate“People's care plans consisted of incomplete information in relation to their cultural and religious needs and preferences.”
critical“Possible risks were identified but an assessment had not been carried out and guidance for care workers on how to reduce these risks had not been provided.”
complaints handling
2 findings
moderate“I was told that they would look into the matter and things improved for a few days but then it slipped and I'm back on the phone again.”
critical“The agency did not view verbal complaints as formal complaints but as a misunderstanding about the service delivery. The agency did not have a central register of these conversations.”
medication management
2 findings
critical“The log book did not contain the list of medicines and the dosage that people had been prescribed to take.”
critical“If (medicines are) in blister pack we give and record in the book. If there is a lot we get confused and don't give it.”
person centred care
2 findings
moderate“Two people also told us that their care had been planned with the local authority but not the agency. People, or where appropriate, their legal representatives had not signed them.”
moderate“Most people told us that they had not received a visit from the registered manager or the care coordinator, and had not taken part in the planning of their care.”
safeguarding
1 finding
critical“We were made aware of three specific incidents of abuse of people by their care workers. People told us they reported their concerns to the agency but the carers came back to intimidate the people.”
incident learning
1 finding
moderate“The agency did not have a central accidents and incidents register which would allow it to analyse and identify any possible trends in the types of incidents and accidents recorded.”
staff competency
1 finding
moderate“Not all of them had a good understanding of the principles of safeguarding vulnerable adults from abuse.”
cultural competency
1 finding
minor“One person's care plan stated care workers should respect the person's religion and culture, however, it did not say what the person's religion and culture were.”
staff training
1 finding
minor“Staff told us that as part of the safeguarding training, they were informed of the principles of the MCA but did not receive in depth training.”
leadership
1 finding
minor“People we spoke with told us they did not know the registered manager and did not have any contact with them.”