critical“care plans had been developed to guide staff about what care people required, there was insufficient detail of how care should be carried out safely”
critical“Some areas of risk, such as choking, mobility or specific health conditions had not been assessed at all.”
critical“people's care records lacked detail and we were not assured that people were receiving person-centred care. People's life history had not been recorded.”
consent capacity
2 findings
critical“where people may have lacked capacity, mental capacity assessments had still not been completed... no record of how decisions had been made in their best interests”
critical
“The provider did not work within the principles of the MCA... best interest decisions were not in place”
governance
2 findings
critical“Quality Assurance systems and systems to monitor staff practice were ineffective. Systems to manage risks to people's health and well being were not sufficiently detailed.”
critical“No audits were being completed at the service. This meant there were no systems for identifying, capturing and managing organisational risks and issues”
leadership
2 findings
critical“The registered manager's skills, knowledge and understanding of their role required further development to enable them to fully understand how to make improvements”
critical“There was a significant lack of provider oversight at this service. The provider had failed to develop effective systems and processes”
staff competency
2 findings
moderate“spot checks... lacked detail about how this judgement was made... did not demonstrate that the member of staff's competency had been sufficiently assessed”
critical“Competency checks relating to administering of medication were not taking place.”
medication management
2 findings
moderate“Checks to assess staff's competency in relation to medicines management formed part of the provider's spot check process. However, this was not robust”
critical“Medicines were not managed safely. Only two members of care staff, out of the nine staff actively providing support to people... had received the appropriate medicines administration training”
person centred care
2 findings
moderate“not sufficient information within care documentation to ensure people were receiving care that met their needs, preferences and individual characteristics”
critical“Staff did not understand the term 'person-centred' and care plans were not personalised.”
record keeping
2 findings
moderate“The provider did not have a system in place to monitor care calls to ensure care was provided at the right time, for the correct duration and that no calls were missed.”
critical“Medication records we reviewed were incomplete... There were no medication records in place for people who were self-medicating but required prompting.”
communication with families
2 findings
minor“The service did not currently provide information in different formats... they had not considered whether these people may have benefitted from information being provided to them in different formats.”
moderate“Not all people's communication needs had been considered or assessed... no further details providing guidance on how to best support the individual's communication needs.”
safeguarding
1 finding
critical“the provider who was unaware that they needed to notify safeguarding concerns to both ourselves and the local authority”
staff training
1 finding
critical“Staff had not completed essential training to provide safe and effective care. This exposed people to greater risk of harm.”
complaints handling
1 finding
critical“The provider had failed to establish an accessible system to identify, record and respond to complaints.”
infection control
1 finding
critical“The provider was not checking that staff were following COVID-19 guidelines to prevent the spread of infection.”
supervision appraisal
1 finding
critical“there was no formal induction for new employees, supervisions, appraisals or competency assessments taking place for staff”
incident learning
1 finding
critical“Recording of incidents and accidents was not taking place at the time of our inspection.”
missed or late visits
1 finding
moderate“The provider had failed to put systems in place to monitor late or missed care calls.”
end of life care
1 finding
moderate“Staff confirmed they had not completed any end of life training with the service. This meant that EOL care may not be as dignified as it could be”