critical“People had been deprived of their liberty without the appropriate legal authorisations being sought from the Court of Protection.”
minor“We did not see that people, or their legal representatives, had always signed to consent they agreed with how support and care would be provided to them.”
governance
2 findings
moderate“Whilst this was not the immediate responsibility of the provider, they had not through their own systems, identified or taken action in response to this shortfall.”
critical“The provider's systems and processes had not been effective in assessing, monitoring and mitigating risks to the health, safety and welfare of people using the service.”
communication with families
2 findings
minor“The service did not always receive positive feedback from professionals in relation to partnership working and communication.”
minor“Some relatives felt that their family members sometimes struggled to understand care staff accents and felt this caused a barrier with having to explain certain things.”
missed or late visits
1 finding
critical“Staff are often late, and visits can be rushed. [Person's] visits should be 45 minutes long, however, very often staff will rush off after 10 to 15 minutes”
medication management
1 finding
critical“Medicines were not consistently managed safely... I do [person's] medicines now, because the carers don't always come on time to do this.”
care planning
1 finding
critical“Records held conflicting information and did not always reflect current best practice of care planning. This meant people were at risk of not receiving the care and support they required.”
record keeping
1 finding
critical“The provider had failed to ensure there were accurate and complete records in respect of each person, to evidence the care and treatment provided to them was in line with their assessed needs.”
safeguarding
1 finding
critical“we were not assured that the registered manager understood what concerns should be shared with the appropriate bodies... The registered manager stated they had not considered this.”
staff competency
1 finding
moderate“concerns had been raised by a health professional about a member of care staff administering medicines they had not been deemed competent to do so safely.”
other
1 finding
critical“Recruitment procedures were not always operated effectively to ensure staff employed were of good character or suitable for the role.”
infection control
1 finding
moderate“staff told us that at times they were short of gloves for personal care tasks... one relative that staff did not always use the correct personal protective equipment (PPE).”
end of life care
1 finding
moderate“The service supported people during the end of their lives, however, people did not have end of life plans in place which considered their wishes and preferences.”
complaints handling
1 finding
moderate“Two relatives said they experienced late calls and raised a complaint about this, although there was no record of this on the complaints log we were provided with.”
person centred care
1 finding
moderate“Care plans were not personalised. We looked at five care plans and found the wording was the same in certain sections of care plans.”