moderate“information within some risk assessments was not fully personalised, which meant standardised statements could be potentially misleading for staff”
moderate“1 person's care plan contained information about 3 different types of epileptic seizures without specifying which type of seizures the person normally experienced”
moderate“Some care plans contained incomplete or unclear information, meaning staff did not have full information to inform them about relevant risks.”
missed or late visits
2 findings
moderate“The carers are very nice, some are a bit rough and they seem to be in a rush and a hurry to get to the next call”
moderate
“Visit records showed evening visits were regularly carried out around one hour later, with some visits recorded after 10.30pm, and two recent visits commencing after 11pm.”
medication management
2 findings
minor“1 person's risk assessment did not include the storage location for their prescribed creams or include the potential fire risk associated with the use of emollient creams”
critical“Records did not evidence safe medicines administration had consistently taken place. This was a breach of Regulation 12”
incident learning
2 findings
moderate“not all incidents had been logged on the system. This meant we could not be assured this data available to the registered manager was fully accurate”
moderate“There was no evidence the service had undertaken an audit or wider analysis of accidents and incidents to identify themes, trends, or where further action may be required”
record keeping
2 findings
minor“1 staff member's file contained 3 documents relating to another staff member…the service had failed to display its rating at the office location and on its webpage”
moderate“Records maintained were not always complete, accurate and kept up to date, as seen in staff recruitment files, quality assurance audits, safeguarding records”
safeguarding
2 findings
minor“We identified one incident witnessed by care staff where the service had not sought guidance from the local authority as to whether the threshold was met for a safeguarding referral”
critical“The registered manager failed to report any of these allegations to the local authority...placed at risk of harm because the registered manager failed to recognise what was a safeguarding incident”
person centred care
2 findings
minor“there was limited and variable information gathered about people's wider social needs, such as their culture and interests”
moderate“The assessment, review and delivery of care was not always personalised to people's needs and preferences. This was a breach of Regulation 9”
governance
1 finding
critical“Quality assurance systems and processes used to assess and monitor the service were ineffective. This was because audits were either not undertaken regularly or in some instances were not completed at all.”
leadership
1 finding
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
complaints handling
1 finding
critical“Systems were not effectively operated and accessible for identifying, handling and responding to complaints. This was a breach of Regulation 16”
infection control
1 finding
critical“Systems were not operated effectively to ensure appropriate infection control measures in response to the COVID-19 pandemic.”
staff training
1 finding
moderate“only four staff had received training in relation to supporting 'challenging' behaviour. A relative expressed concern about whether all staff were competent”
supervision appraisal
1 finding
moderate“supervision policy stated staff should receive six formal supervisions a year but supervision records viewed showed this did not happen.”
communication with families
1 finding
moderate“The communication needs of people with disability or sensory loss were not always met. This was a breach of Regulation 9”
cultural competency
1 finding
minor“Another person had a cultural preference for female staff, and experienced episodes of distress, but received some care from male staff”
other
1 finding
critical“Systems were not consistently operated for the safe recruitment of staff. This was a breach of Regulation 19”