minor“We have asked for female carers and a small team, but they haven't done that yet”
critical“The provider remains in breach of regulations found at the last inspection. These relate to person centred care, safeguarding people from abuse, receiving and acting on complaints, good governance, duty of candour and staffing.”
critical“Processes for assessing and reviewing people's needs were not fully effective in ensuring care met people's needs and preferences.”
record keeping
3 findings
minor“We did not always see evidence of documented findings from these daily audits”
minor
“For one person, information about their needs was not always consistent through their care plan. The manager told us they would take direct action to rectify this.”
critical“People's care records were not up to date and did not reflect current care.”
governance
3 findings
minor“[Surveys are] once a year they do send a questionnaire it's not very good very basic”
critical“The provider remains in breach of regulations found at the last inspection. These relate to person centred care, safeguarding people from abuse, receiving and acting on complaints, good governance, duty of candour and staffing.”
critical“The provider's systems and processes in place to assess, monitor and mitigate risks and to improve the quality and safety of the service were not always effective.”
staff training
2 findings
minor“some people felt staff needed further training when it came to meal preparation, and there wasn't always enough time to complete cooking tasks”
critical“staff had not received training in; fluid and nutrition, MCA, dementia, food hygiene, safeguarding and infection prevention.”
safeguarding
2 findings
critical“The provider remains in breach of regulations found at the last inspection. These relate to person centred care, safeguarding people from abuse, receiving and acting on complaints, good governance, duty of candour and staffing.”
critical“The service had failed to implement effective systems to identify, investigate and appropriately respond to allegations of abuse.”
complaints handling
2 findings
critical“The provider remains in breach of regulations found at the last inspection. These relate to person centred care, safeguarding people from abuse, receiving and acting on complaints, good governance, duty of candour and staffing.”
critical“Systems were not operated effectively for identifying, receiving, recording, handling and responding to complaints.”
staffing levels
2 findings
critical“The provider remains in breach of regulations found at the last inspection. These relate to person centred care, safeguarding people from abuse, receiving and acting on complaints, good governance, duty of candour and staffing.”
critical“The registered person did not ensure there were sufficient numbers of staff deployed effectively to meet people's care and treatment needs.”
medication management
2 findings
critical“One person's care plan contained conflicting information regarding the support they required with their medicines, this put them at risk of missing or receiving too much of their medicines.”
critical“The service had not ensured the proper and safe management of medicines, including record keeping of the administration of medicines.”
care planning
2 findings
critical“People who received reablement care (short-term care after hospital stays) did not have risk assessment in place, this included general risk assessments and mobility risk assessment.”
critical“Risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient detail to help staff understand and respond to risks.”
infection control
2 findings
moderate“At the last inspection we were told by one person using the service that topical medicines were not always applied with the correct use of PPE.”
moderate“The provider did not have processes and systems in place to ensure that all staff met their responsibilities in relation to preventing and controlling infection.”
incident learning
2 findings
critical“At the last inspection, accidents and incidents were not documented, therefore action taken to assess the risk was not effective to ensure service users were kept safe.”
critical“records did not include further investigation, analysis, action or outcome to consider how incidents occurred and steps taken to try to prevent a reoccurrence.”
cultural competency
1 finding
minor“Cultural language can be a problem, I have quite a few whose first language is not English, and I have to explain things I've said to them”
supervision appraisal
1 finding
moderate“Staff members were not supported to reflect on their working practices through regular supervisions.”
leadership
1 finding
critical“The registered manager did not have an adequate understanding of their role, regulatory requirements and lacked oversight of the service.”
missed or late visits
1 finding
moderate“lots of lateness. I like to have my breakfast at 9am, sometimes they don't come until 11.30am”
staff competency
1 finding
critical“Stoma care was being carried out by staff despite staff having not been trained.”
other
1 finding
critical“The registered person did not follow and accurately record and keep a copy of all the actions taken as required in the regulation when a notifiable safety incident occurred.”