critical“Risk management plans were either not in place and/or not detailed to ensure that there was up to date person-centred guidance for staff on what to do should people become ill.”
moderate“Risk assessments and care plans were not always updated when there had been a change in the person's needs to ensure that staff had the appropriate guidance when offering the person support.”
staff training
2 findings
critical“Staff had not undertaken training that was relevant to the people they were supporting. This included epilepsy, diabetes, Parkinson's disease and catheter bag training.”
moderate“We found that safeguarding training for all staff was not up to date.”
governance
2 findings
critical“Quality assurance processes had failed to effectively identify and address the issues identified during this inspection. Staff told us that care plan audits had ceased when the provider moved to an electronic system in November 2021.”
moderate“audits to monitor and assess the quality and safety of the service had not been carried out... the provider did not undertaken medicine audits to check the quality of medicines records”
record keeping
2 findings
moderate“Robust records, which included risk assessments and care plans were not always accurate or complete.”
moderate“one person had undergone an operation. We found that their care plan had not been updated after this event to identify the risks involved or any guidance for staff”
medication management
1 finding
critical“Medicines were not always safely managed. The provider did not always maintain accurate medicine administration records.”
safeguarding
1 finding
critical“The provider had not made any safeguarding referrals since the last inspection in 2017. Whilst accidents in relation to a pattern of unexplained bruising or a fracture were recorded, they were not investigated.”
incident learning
1 finding
moderate“Accidents and incidents were not analysed for trends/themes and learning was not always disseminated to staff so there could be a positive impact in improving people's experience.”
staff competency
1 finding
moderate“There was no process in place to assess staff competency to ensure they had the right skills and know to carry out their roles effectively.”
supervision appraisal
1 finding
moderate“Staff files reviewed, and staff spoke to confirmed that staff were not supported with regular 1:1 supervisions. One staff member said, 'Last supervision I had was 2-3 years ago.'”
consent capacity
1 finding
moderate“The registered manager and some staff were not able to demonstrate a clear understanding of the principles of MCA and when it should be applied.”
person centred care
1 finding
moderate“People's care plans were not always person-centred and contained minimal information about people and their health and care needs.”
complaints handling
1 finding
moderate“The registered manager told us that they had not received any complaints to date. However, we saw a number of incidents that should have been classified and investigated as complaints.”
missed or late visits
1 finding
minor“The system calculated 5 minutes between calls that was not a realistic amount of travel time. They said that this meant they were late for the next call.”
communication with families
1 finding
minor“Some staff told us they were hesitant to contact the registered manager for advice and guidance as communication with the registered manager needed improving.”