critical“This is a breach of Regulation 17 of the HSCA 2008 (Regulated Activities) Regulations 2014, Good governance”
minor“I get a list but it isn't always correct and they don't let me know if they have changed it”
supervision appraisal
2 findings
critical“Staff did not receive consistent managerial support and there was no clear line of accountability. One person told us they had not received supervision in two years.”
moderate“I have not received any form of supervision in the last year”
missed or late visits
2 findings
moderate“Staff told us they had raised concerns about this informally on numerous occasions but action had not been taken... the registered manager told us that a new recruitment drive hoped to alleviate the pressure”
moderate“The staff are usually on time but if they are late they don't let me know I have to call them”
record keeping
2 findings
moderate“Systems in place were informal which meant that information could be lost. We saw limited documentation which meant the information might not be communicated effectively to others.”
moderate“we saw some inconsistencies about the quality of written guidance for staff. On some care plans it was very detailed whilst on others the guidance was minimal.”
person centred care
2 findings
minor“one care plan informed staff that a person had cultural preferences for care, but it did not specify what these were. This meant staff might not have all the information they needed.”
moderate“whilst they had expressed a preference for not having male staff, male staff were sent to them when the service was short staffed”
consent capacity
2 findings
minor“The registered manager had filled in forms to say that people had consented to their care arrangements but people did not sign to say they were involved in planning for their care.”
minor“a review of how these were completed was needed as they were not always completed correctly for each activity which needed an assessment”
care planning
1 finding
minor“some care plans were not always detailed enough for people who had complex needs such as those who lived with dementia or those who needed end of life care.”
medication management
1 finding
minor“staff were recording giving medicines in two different places which made auditing people's medicine administration records (MAR) difficult.”
staff training
1 finding
minor“staff were not currently receiving specific training in oral health care, there were plans to introduce this to the new training programme which was under development.”
communication with families
1 finding
minor“They don't always arrive on time, but they have good reason why they are late, it was more that the service did not let them know”