critical“Quality assurance processes were ineffective in driving improvement. This was a continued breach of Regulation 17.”
critical“Records relating to the management of the service were either partially completed or not completed at all and not fit for purpose.”
record keeping
2 findings
moderate“Daily records written by care staff were of a poor quality. 'There's no detail about the person in the report it's just repeated sentences around the jobs they have done'.”
critical“When visiting the home of a person, we found personal information relating to another person who used the service, in the person's care plan.”
supervision appraisal
2 findings
critical“One person had been employed since 2017, they had one recorded supervision meeting on file.”
moderate“One staff member had a partially completed spot check whilst there were no records of spot checks in the other staff files we viewed.”
consent capacity
2 findings
critical“The person had scored five out of 30 [MMSE], demonstrating severe memory loss. However, no capacity assessment had been completed.”
moderate“A person's care record stated they lacked capacity to make decisions... the person had signed to give consent for medicines to be administered.”
complaints handling
2 findings
critical“Records relating to complaints were incomplete and did not demonstrate the complaint had been acknowledged or investigated.”
minor“Out of the two homes visited we found only one person had the complaints procedure in their care records.”
care planning
2 findings
moderate“Care plans did not provide adequate guidance for staff on how to support people with their medical conditions.”
moderate“People's needs and identified risks were reviewed... care documents did not support this. The registered manager acknowledged this.”
medication management
1 finding
critical“Care staff hand wrote onto the MARs, they did not routinely include the name of the prescribed medicine, the dose, route or frequency.”
staffing levels
1 finding
critical“Two don't always come and the one is on the phone trying to find a second person.”
staff training
1 finding
moderate“No formal system was in place to ensure staff received training when required. Refresher training was overdue for several staff members.”
missed or late visits
1 finding
moderate“We had to put [Name of person] to bed as they were due between 6:30pm and 7pm but nobody by 8:45pm so we did it.”
safeguarding
1 finding
critical“The service had reported an alleged theft to the police. The service failed to inform us about this. One person had fallen resulting in a fractured hip.”
leadership
1 finding
moderate“The registered manager did not attend the office on a weekly basis. One member of staff told us the registered manager had been in the office twice a month.”
incident learning
1 finding
moderate“Accidents and incidents were not routinely analysed to look for themes and trends.”
cultural competency
1 finding
moderate“'They [Care staff] talk so fast it's hard, it's a job to understand' and 'They do try and talk to mum, and they smile a lot, but English is a problem.'”
person centred care
1 finding
moderate“'I have an elaborate care plan, but they don't stick to it. I think it's written to get our business. It's never been reviewed.'”
end of life care
1 finding
minor“The question in regards to their end of life care wishes and preferences was left blank by staff. The person told us staff had not asked them questions.”