moderate“quality assurance processes introduced since our last inspection were not fully embedded to always drive ongoing improvements to the service”
critical“Systems in place to monitor compliance with the regulations were not effective and had failed to identify that compliance was not consistently achieved.”
record keeping
2 findings
moderate“some people's care records we sampled did not always reflect the full extent of people's needs and risks to always clearly guide staff as needed”
moderate“one person's daily fluid and food monitoring notes were not consistently completed, with gaps in one person's daily records for up to 19 days on one occasion.”
care planning
2 findings
moderate“one person's care plan omitted an aspect of the support they received to manage a healthcare condition, and the details of the guidance and training provided to staff”
moderate“There was no detailed guidance for staff about how they were to protect people from the risks associated with their health conditions.”
consent capacity
2 findings
critical“information was not recorded in adherence with the Code of Practice of the Mental Capacity Act (2005)... one person's care plan contained a small written note relating to their advance decision”
moderate“although staff provided examples of how they encouraged people to make their own choices, they were not aware of the MCA.”
complaints handling
2 findings
moderate“feedback and complaints had not always led to sustained improvements to the overall quality of the service provided”
moderate“We saw that no complaints had been recorded since 2013, however...some issues raised...met the definition of a complaint...but had not been addressed as such.”
missed or late visits
2 findings
minor“some staff occasionally being late for people's calls and leaving calls too early”
critical“records confirmed that people often experienced late calls and in one instance a person received their call one hour and 20 minutes late.”
person centred care
1 finding
moderate“people could not always be confident therefore that they would receive a consistently caring service”
communication with families
1 finding
minor“systems had not ensured people's feedback was directly addressed and acted on following their involvement in quality assurance calls”
medication management
1 finding
critical“Records of medicines administered were inconsistent with the records of prescribed medicines...it was not possible to identify whether staff had supported people to take their medicines as prescribed.”
staffing levels
1 finding
critical“No review or action had been undertaken to identify if there were insufficient numbers of staff employed or if the deployment arrangements needed to be changed.”
incident learning
1 finding
moderate“We found that incidents were not always used as a learning opportunity to improve how risks were managed.”
safeguarding
1 finding
moderate“the registered manager had not met their requirements in relation to informing us of safeguarding incidents and concerns that had occurred.”