critical“Comprehensive assessments of each person's physical and mental health were not conducted before accepting the care package.”
moderate“People with identified learning disabilities did not have this documented within their care plans or considered, such as how this may affect their understanding.”
moderate“Entries in care plans were confusing and contradictory. One person who used a wheeled walker was recorded to not use mobility aides and be at low risk of falls.”
safeguarding
2 findings
critical“The provider had failed to safeguard people from abuse and improper treatment. This was a breach of regulation 13 Safeguarding of the Health and Social Care Act 2008.”
critical
“The registered manager had not notified the Commission of a safeguarding incident. Statutory notifications are required to be submitted where there are allegations of abuse.”
staff training
2 findings
moderate“Staff had not completed their annual training. One staff member had not completed 17 of their 22 training modules and continued to provide care during this period.”
moderate“Staff told us all the training was online and some felt it did not provide them with the opportunity to apply the learning in practice.”
staffing levels
2 findings
moderate“A person told us, 'They couldn't give me my time for the visit as everyone wants that time and they didn't have enough carers.'”
critical“Staff told us they are expected to do multi handed calls on their own if there are not enough staff. Another told us they responded by 'Cutting corners…We don't have time to watch them eat.'”
governance
1 finding
critical“The provider had failed to ensure effective systems and processes were established and operating effectively to assess, monitor and improve the service. Breach of regulation 17.”
incident learning
1 finding
moderate“The registered manager told us they spoke with staff at the time of concerns being raised but did not retain records to identify themes or learning.”
supervision appraisal
1 finding
moderate“Staff told us their practical assessments were pre-populated and they were not spot checked during visits to ensure standards of care were maintained.”
leadership
1 finding
moderate“Some staff told us they felt unable to raise concerns with managers without fear. Two staff members told us if they complained they were 'put on the naughty step' and their hours were reduced.”
record keeping
1 finding
moderate“Records did not include actions taken by staff to reduce/manage the risks of people not taking their medication, failing to have bowel movements for days or confirming food/fluid consumption.”
complaints handling
1 finding
minor“Staff told us the management team had asked them to apologise to a person on their behalf but did not provide information on actions taken to address the complaint.”