critical“The registered manager did not have appropriate knowledge and skills in relation to the principles of the MCA. People's capacity was not assessed appropriately.”
critical“No staff had received training in relation to the MCA. The provider recognised improvement was required in this area.”
critical“The provider was not working in line with their own policies... No assessments were undertaken for people. This meant consent to care and treatment was not always sought.”
care planning
2 findings
critical“where a person required assistance to mobilise using a hoist. No specific risk assessment or care plan was in place to give staff guidance about how to safely move this person.”
critical
“One person's care plan stated the person required the use of a hoist and later stated the person was mobile. This did not support staff to understand people's needs.”
governance
2 findings
critical“Some audits were not completed in a timely manner and did not always identify concerns found during our inspection.”
critical“Auditing systems were not effective in identifying or actioning concerns. Audits lacked information and did not detail issues found during our inspection.”
record keeping
2 findings
critical“Records used for monitoring risks to people's skin, mobility and consent forms were not fully completed. There were no accurate records of people's ability to make decisions.”
moderate“Records containing information relating to care call times were not always completed. The registered manager could not produce documents in a timely manner throughout our inspection.”
staff training
2 findings
moderate“Staff still required training about the MCA and how this is applied into practice.”
moderate“Staff training records covered a range of topics studied in 1 day. Multiple training topics were covered in one day, meaning staff were not provided with enough time to develop their learning.”
medication management
2 findings
minor“Staff had received medicines training and initial competency checks. Improvement was needed to ensure staff received ongoing medicines competency assessments.”
critical“Two relatives told us that medicines errors had occurred. These were not recorded by the service, therefore it is unclear what action was taken arising from these errors.”
communication with families
2 findings
minor“Some people and their relatives told us they were sometimes having trouble communicating with some staff due to English not being their first language.”
moderate“A relative told us, 'The service does not ring and check up on [name] and they don't inform us of any changes.' Some people and relatives told us there were barriers to communication.”
person centred care
2 findings
minor“Some records remained vague about people's choices... Care plans could be improved to provide more person-centred detail about people's choices and wishes.”
critical“Care records contained little or no background information about people or their choices, likes and dislikes. One person told us, 'I haven't got a care plan.'”
missed or late visits
1 finding
moderate“Records showed multiple occasions where staff were late for calls, it was not evident what action had been taken to address this.”
supervision appraisal
1 finding
moderate“Some supervisions were not conducted in a timely manner and robust systems were required to ensure staff received regular supervision meetings.”
safeguarding
1 finding
critical“During the inspection we made three safeguarding referrals to the local authority, which had not been previously raised by the registered manager.”
staffing levels
1 finding
critical“People were not receiving staff at the appropriate times or for the allocated time to meet their needs. One person said, 'I am supposed to have 2 staff to help me, but they often send 1.'”
staff competency
1 finding
moderate“The majority of relatives we spoke to told us they were concerned about staff competency. One relative said, 'The staff are like they have come with no training.'”
incident learning
1 finding
critical“Accidents and incidents were not accurately recorded or monitored. Records did not detail if an investigation or root cause analysis was undertaken.”
complaints handling
1 finding
critical“Complaints were not accurately recorded. Relatives told us they had raised complaints with the registered manager. These were not provided to us through the service's complaints logs.”
infection control
1 finding
moderate“Staff did not always wear appropriate personal protective equipment (PPE). One staff had supported a person during the night without wearing a uniform or PPE.”
leadership
1 finding
critical“The registered manager did not have an adequate understanding of their role, regulatory requirements and lacked oversight of the service.”