critical“They continued to apply a blanket assessment to people who had capacity to make their own decisions...had not completed these at the time of the inspection.”
minor“the registered manager had assessed capacity regardless of considering if this applied. This is not in line with the principles of the MCA 2005.”
moderate“People were asked for consent to care and support but the process was inconsistent. The consent policy had not been reviewed since 2015.”
staff training
3 findings
moderate“Staff had not completed training in other areas...These included risks of choking, diabetes and skin integrity.”
minor
“we found shortfalls in some areas of training around end of life and diabetes. Subsequent to the inspection the registered manager informed us this training had been arranged.”
critical“The provider did not have adequate training or systems in place to ensure staff had the skills and knowledge to enable them to provide safe and effective care. This was a breach of Regulation 18.”
governance
3 findings
critical“Audits in place to assess the quality and safety of the care provided were not effective in identifying improvements.”
minor“Actions from previous meetings were not reviewed, and key agenda items required for discussion at each meeting were not identified.”
critical“The provider did not have adequate systems and processes in place to monitor the quality and safety of the service. This was a breach of Regulation 17 HSCA RA Regulations 2014 Good governance.”
record keeping
3 findings
moderate“Some daily logs of the care provided were ineligible and could not be read.”
moderate“auditors had not identified care records lacked detail relating to supporting people in a person centred manner. For example where people identify they may need help when anxious, the record does not instruct staff how to specifically support this person.”
moderate“Care plan and recruitment files audits that had been completed had not identified the lack of missing information, missing dates in risk assessments and missing signatures.”
care planning
2 findings
critical“People's care plans included a list of healthcare conditions. The provider had assessed and planned for some, but not all of these.”
moderate“Peoples care plans were pre-populated and did not always relate to the needs of the individual. This was confusing for staff especially new staff who were not familiar with peoples assessed needs.”
missed or late visits
2 findings
critical“I expect them at 5pm and they turn up at 6pm...Sometimes I can end up with a wet bed and that is not good.”
minor“Three people we spoke with told us that they had experienced late calls on occasions.”
incident learning
2 findings
moderate“Procedures to learn and develop staff practise when things went wrong were not in place...meetings with staff did not discuss any concerns, accidents or incidents.”
moderate“There was no follow up or investigation by the registered manager to determine the cause of the skin damage and no measures were put in place to prevent further deterioration.”
staff competency
2 findings
moderate“The registered manager was not aware of the differences between prompting or administering medicines...Staff were equally unaware of the difference.”
critical“Not all staff had effective moving and handling training before supporting people who required to be transferred with the use of hoists and sling. This put people at risk of unsafe care.”
medication management
1 finding
critical“Some put them in a tumbler and I try to get them out with my fingers...they don't make sure I am ok, some are better than others and I need more help than just popping them on the table.”
communication with families
1 finding
moderate“Staff shared intimate information relating to people's choices and care with family and friends...no discussions with people to ensure they were happy to share their information.”
end of life care
1 finding
minor“Care records also did not always record that conversations had taken place around people's wishes for end of life care.”
safeguarding
1 finding
critical“Staff had little knowledge about safeguarding, what constituted abuse and what the reporting process was. One staff member told us, "You need to make sure everyone is ok"”
staffing levels
1 finding
critical“One staff member was covering all the visits for all people using the service and working seven days a week without adequate rest periods.”
supervision appraisal
1 finding
moderate“Staff received some formal support from the registered manager but there was no schedule to show the frequency or agenda of discussions held. Two of the three meetings were terminated prematurely.”
complaints handling
1 finding
minor“There was a complaints policy in place however this had not been reviewed since June 2012 so we could not be assured it was still current.”
person centred care
1 finding
moderate“"My visit is often provided much later than I would like. I asked them if I could change the time... but was told 'Your slot is [time] and that is all we can do.'"”
leadership
1 finding
moderate“The registered manager was unable to demonstrate they fully understood their individual responsibilities to providing a service under the Health and Social Care Act 2008.”