minor“for some risk assessments it was not always clear what action staff should take if concerns were noted. This was discussed with the provider who took immediate action to address this.”
critical“The provider told us, 'I know this information but it's in my head, not on paper.' Care records were not person centred and did not reflect people's assessed needs and choices.”
medication management
2 findings
minor“we identified guidance for staff was not always detailed about how to support people with this medication when needed. This was discussed with the provider who confirmed this would be immediately addressed.”
critical“One person had a medicine prescribed four times a day, but there were no times documented on the MAR...putting the person at risk of being administered medicine too soon which could have resulted in an overdose.”
end of life care
2 findings
minor“we identified more information was required to help ensure people's wishes and preferences were understood by staff and adhered to. This was discussed with the provider who agreed to review these care plans.”
critical“One person was receiving end of life care. This person's care plan was not fully completed and did not demonstrate this person's end of life wishes had been adequately explored.”
safeguarding
1 finding
critical“The Local Authority had identified at least nine safeguarding incidents this year that related to missed and late care calls and failing to seek medical support in a timely way.”
staffing levels
1 finding
critical“They have so many customers so they can't keep on time, once they never turned up, but they apologised...They don't always stay for the full time.”
governance
1 finding
critical“The provider failed to follow their own governance policy to ensure they had sufficient oversight of quality and safety within the service.”
missed or late visits
1 finding
critical“Feedback from people and their relatives had been received by the provider which raised a number of concerns/complaints with a similar theme of late/missed care calls. There was no evidence action had been taken.”
complaints handling
1 finding
moderate“There was no system in place to investigate and respond to complaints...one relative told us of a complaint they had made to the provider in February 2022, but they had not received a response.”
record keeping
1 finding
moderate“The provider failed to ensure records were accurate, contemporaneous and up to date...care planning documentation contained out of date, conflicting or inaccurate information.”
person centred care
1 finding
critical“Where end of life care was being provided, care plans were not person centred or reflective of the current level of support required.”
staff competency
1 finding
moderate“Staff were not able to clearly describe the basic principles of the MCA. One staff member believed it related to being taken care of by someone else and said, 'Where someone can be taken of, I'm not sure.'”
incident learning
1 finding
critical“Provider's investigations did not always contain sufficient detail as to what action would be taken to prevent reoccurrence. This placed people at continued risk of harm.”
leadership
1 finding
critical“The provider did not have a good understanding of their regulatory requirements and neglected their management duties...led to poor governance systems, lack of meaningful quality assurance processes.”
consent capacity
1 finding
moderate“One person's care plan had a contradictory assessment of their capacity and the consent form had been signed by a relative on their behalf.”
communication with families
1 finding
moderate“People's communication needs had not always been adequately assessed or recorded...one person's care plan stated they were registered blind and hard of hearing but had no guidance on how staff should support them.”