critical“Medication risk assessments were not always in place for people who were supported to take their medication.”
moderate“Not all staff completing the competency assessments had completed their training to ensure they were completing the checks appropriately.”
critical“We could not be confident medicines were administered as prescribed. Medication audits had not identified all of the issues with the medicines administration records”
care planning
2 findings
moderate“Although new care plans and assessments were in place the auditing system had failed to identify missing information.”
critical
“Care plans were contradictory and did not always contain all of the information staff needed to support people in the way they preferred.”
governance
2 findings
critical“The governance process in place had not identified that not all complaints were being recorded.”
critical“The registered manager had not carried out any quality monitoring or audits that may have identified the improvements needed.”
complaints handling
2 findings
critical“One person had complained that they had money missing from their house. However, this was not recorded in the complaints log.”
critical“Complaints were not always being dealt with in an appropriate or timely manner. The providers complaints process was not being followed when a complaint was received.”
person centred care
2 findings
moderate“My only comment is them [care staff] talking to each other and I can't understand a word. Washing me on the bed and talking to each other in their own language.”
moderate“The wording used in some care plans was disrespectful towards people and could cause confusion for staff.”
record keeping
2 findings
minor“Records were not always written in a way that promoted people's dignity. For example, one care plan referred to a person needing help to clean their bowel region.”
critical“Record keeping was poor and records were incomplete and inaccurate. Care plans and risk assessments did not include all current information”
consent capacity
1 finding
moderate“One person needed an MCA and best interest decision regarding the administration of medication.”
missed or late visits
1 finding
critical“Some people had experienced missed and late calls, and this had put them at risk of not receiving the care and support they needed.”
infection control
1 finding
critical“Staff were not carrying out the required twice weekly lateral flow tests to prevent the spread of infection.”
staff training
1 finding
critical“some staff had not updated their training since 2017. This placed people at risk of receiving inappropriate care.”
staff competency
1 finding
critical“recently employed staff had not completed competency assessments before working with people on their own.”
supervision appraisal
1 finding
moderate“The records showed that staff had not received regular supervision or annual appraisals.”
leadership
1 finding
critical“There had been a significant lack of effective management over a considerable period of time. This had adversely impacted on the care people received”
end of life care
1 finding
moderate“One person being supported was receiving end of life care. However, the provider had not considered having a conversation with them about their preferences for end of life care.”
other
1 finding
critical“The provider had failed to ensure that they recruited staff through robust, safe procedures. This was a breach of regulation 19 (Fit and proper persons employed)”
incident learning
1 finding
minor“The provider stated that there had not been any accidents or incidents in the previous 12 months.”