critical“The provider failed to have effective systems in place to assess, monitor and improve the quality and safety of the service, to act on feedback from service users, to monitor and mitigate risks”
record keeping
1 finding
critical“The failure to maintain an accurate, complete and contemporaneous record in respect of each service user was an ongoing was a breach of Regulation 17”
care planning
1 finding
moderate“not all people's care plans contained sufficient detail to mitigate known risks. Although some people's care plans did have detailed information about risks, this was not consistent.”
leadership
1 finding
moderate“six out of seven staff spoken with felt underappreciated and undervalued. One staff member said, 'The [registered] manager is unapproachable, we have a meeting but nothing changes.'”
supervision appraisal
1 finding
moderate“some staff told us they did not always feel supported or listened to if they did raise concerns. One staff member said, 'We [staff] have raised concerns with the [registered] manager but we are not listened to and nothing changes.'”
missed or late visits
1 finding
moderate“Staff don't always turn up on time and they don't call and let us know anything about it... The times [of visits] they [staff] come are not good, sometimes they come an hour after they have already been”
staffing levels
1 finding
moderate“feedback we received from staff indicated they did not have enough time to travel to each person in between visits.”
consent capacity
1 finding
moderate“some people who had a diagnosis of dementia and required their medicines administering to them, did not have a decision specific MCA in place for this.”
medication management
1 finding
moderate“one person was allergic to penicillin and there was insufficient detail for staff to recognise signs and symptoms should the person have an allergic reaction and what action they should take.”
complaints handling
1 finding
minor“people and their relatives did not all know how to raise any concerns they might have about their care and support.”
staff training
1 finding
minor“Honestly I thought it [the induction] was too quick for me to get in the field. There was not much time for me to grasp everything I needed to know.”
end of life care
1 finding
minor“While some people's care plans captured their end of life wishes, this was not consistent.”