critical“The provider failed to maintain sufficient numbers of suitably qualified, competent, skilled, and experienced staff to make sure that they can meet people's care and treatment needs.”
missed or late visits
1 finding
moderate“A morning call, due at 8am, was provided at almost 10am, with no explanation as to why or an apology for being late.”
medication management
1 finding
critical“Application of topical medicines and transdermal patches were not routinely recorded on Topical Medicines Application Records (TMARS) and body maps.”
staff training
1 finding
critical“Staff also lacked specialist training related to people's specific conditions, such as peg feeding, oral health and stoma care. One professional told us, 'Staff are not always competent to provide the care and support required.'”
supervision appraisal
1 finding
moderate“Staff supervisions were not routinely planned. The provider's systems did not contain the information to assure us staff received ongoing or periodic supervision.”
governance
1 finding
critical“The provider's quality monitoring systems were not always effective. Regular audits were not conducted to improve service delivery.”
record keeping
1 finding
critical“The provider failed to maintain accurate, and complete records. Some people's daily notes contained unexplained gaps.”
care planning
1 finding
moderate“Not all care plans provided concise guidance for staff about how to deliver people's care and support requirements, for example, in relation to accessing people's property.”
communication with families
1 finding
moderate“English is not their first language, and they don't understand everything I say. The carers can't pronounce the names of my tablets, so they identify them by colour.”
person centred care
1 finding
moderate“A neighbour told me, (Name) had an incontinence accident and the carer started to vomit when going to clean it up and the neighbour had to help clean (Name).”
complaints handling
1 finding
minor“Procedures were in place to investigate and respond to complaints. However, we found these were not always recorded.”
leadership
1 finding
moderate“The registered manager and staff lacked a clear understanding about their roles and did not always have an effective oversight of the service.”