critical“risk assessments contained conflicting and contradictory information about risks and guidance for staff was often unclear.”
medication management
1 finding
critical“The care notes for another person showed they had refused their medicines on several occasions, yet the MAR had been signed to indicate the medicines had been given.”
governance
1 finding
critical“The most recent quality assurance audit found no concerns with care plans, risk assessments, staff files, staff training and staff attendance which is contrary to what we found.”
missed or late visits
1 finding
critical“There were widespread issues with the scheduling, recording, and monitoring of care visits which meant people experienced late and missed visits.”
staff training
1 finding
critical“staff did not receive mental capacity act training and staff we spoke with could not demonstrate how the MCA fitted in to their role.”
record keeping
1 finding
critical“The provider was failing to store personal information about people and staff securely. During the inspection we found care plans and personal staff information being stored in an unsecure way.”
safeguarding
1 finding
critical“despite numerous concerns had failed to make sufficient improvements...not able to explain these anomalies or demonstrate sufficient improvement to their systems and processes despite numerous complaints and safeguarding alerts.”
consent capacity
1 finding
moderate“they did not have a process for assessing people's capacity if they had reason to believe people were not able to make decisions about their care and support.”
complaints handling
1 finding
moderate“"I have complained 5-6 times about things, nothing ever happens. They say they will ring back but they don't. I haven't heard anything."”
incident learning
1 finding
moderate“there was a pattern of similar repeated incidents occurring within the service and the provider's internal investigations had failed to identify root causes.”
leadership
1 finding
moderate“"No complaints about the care staff, just the way its run" and "The management are dismissive about things, they just don't care about the workers."”
person centred care
1 finding
moderate“most care plans did not contain sufficient detail regarding people's routines, and preferences.”
staffing levels
1 finding
moderate“Staff were not given sufficient time to travel from one person's home to another...352 incidents where these staff were not allocated any travel time between calls.”