critical“Yesterday, I should have had some visits. I only had one. I have phoned the agency this morning to see what the problem was.”
critical“People told us there were not enough staff and this meant they missed care visits or received them late.”
moderate“Most people told us staff were late on most occasions. One person said, "They turn up when they feel like it; they either come too early or late."”
staffing levels
2 findings
critical“one person who required two people to assist them with moving and transferring using a hoist, did not receive this support on more than one occasion because care staff were not arriving together.”
critical
“Three of the five care workers we spoke with also told us they did not think there were enough staff. One care worker said, 'No, there's not enough staff.'”
governance
2 findings
critical“missed visits to people, late visits or failures by 'double up' staff to attend visits at the same time, were not picked up by the management team.”
critical“Audits were completed, but they were not effective as they had not identified issues with the quality of records and plans found during the inspection.”
staff training
2 findings
moderate“one staff member told us they had received three days of training in the office...A second member of staff told us they had received one day induction training in the office.”
critical“Staff covered 15 units of the care certificate on one day... Five care staff were unable to explain the Mental Capacity Act (2005) or different types of abuse when asked by the inspector.”
complaints handling
1 finding
moderate“No, I don't know how to complain and I haven't received any information.”
communication with families
1 finding
minor“No the agency don't contact me if they are making changes or if the carers are sick or running late.”
safeguarding
1 finding
critical“Instances of neglect and abuse were not raised as safeguarding issues and staff did not identify neglect as a type of abuse.”
medication management
1 finding
critical“Medicines were not managed or recorded in a safe way. Records were unclear and staff did not have sufficient information to ensure they supported people to take their medicines as prescribed.”
care planning
1 finding
critical“Care plans were task focussed and did not contain information about people's preferences, or how their religious and cultural background or sexuality affected their preferences.”
consent capacity
1 finding
critical“Two care plans stated people lacked capacity; signed by relatives with no record to demonstrate these relatives had legal authority to make decisions on the person's behalf.”
record keeping
1 finding
critical“One person's record showed medicines had been recorded as administered on only four occasions during October 2016.”
incident learning
1 finding
moderate“Although individual concerns had been addressed lessons learnt had not been applied to the whole service.”
cultural competency
1 finding
moderate“In all nine of the care plans viewed, the section relating to culture was marked 'not applicable' or left blank.”
person centred care
1 finding
critical“Records of care showed that people were not consistently receiving care in line with their needs and preferences.”
staff competency
1 finding
moderate“Shadowing records were undated so it was not clear if care workers had completed all the tasks in one session, or over a period of time.”
leadership
1 finding
moderate“A staff member told us, 'I don't feel comfortable to raise issues with the registered manager. Things just get brushed under the carpet.'”