critical“Risk assessments continued not to be completed in relation to people's health conditions such as people at risk of stroke, heart disorder, respiratory failure and diabetes.”
critical“We are waiting for an assessment to be able to devise a care plan and we have been waiting now 2 months. So, no care plan and we have to tell the carers what needs to be done.”
critical“Pre-admission assessments and care plans were not robust to ensure people's preferences with support and care were captured.”
critical“Risk assessments had not been completed for people at risk of falls... robust risk assessments had not been completed to minimise people from falling.”
medication management
4 findings
moderate
“For one person in March 23, staff did not sign the Medicine Administration Chart (MAR) for the whole month.”
critical“MAR charts showed gaps on 6 peoples MAR charts with no information on why these medicines were not administered, which meant there was a risk these medicines were not given”
critical“Medicines were not managed safely in some areas... we did not see any PRN protocols or guidance in place to guide staff on how and when to administer these medicines”
critical“they crush all medicines together and place in the person's tea. Professional advice had not been sought from the pharmacist to check if it is safe to give all the medicines together”
governance
3 findings
critical“These audits did not identify the shortfalls we found at the inspection.”
critical“Audits continued not to find shortfalls we found with medicines, care plans, risk assessments and staff time keeping.”
critical“The registered provider was not robustly assessing, monitoring, improving the quality and safety of the service users and mitigating the risks to ensure people were safe at all times.”
record keeping
3 findings
moderate“The audit findings did not record the action that had been taken to ensure risks of reoccurrence was minimised such as if staff required further training on medicines.”
critical“The medicines risk assessment document often had different medicines listed when compared to the MAR chart such as the dosage and frequency on some risk assessments did not match”
moderate“there was number of blank entries as staff had not logged into calls, which meant the service would not have oversight if staff attended calls on time.”
incident learning
2 findings
moderate“Failure to take robust action when identifying shortfall during audits meant there was a risk it may happen again.”
moderate“robust systems were not in place to analyse incidents and accidents to learn from lessons and minimise the risk of re-occurrence.”
missed or late visits
2 findings
critical“We have had carers arriving as late as 1pm. We are not informed of lateness.”
critical“No, the carers have never arrived on time or stayed the allotted time of half an hour. Carers have only stayed a maximum of 12 minutes for an hour visit.”
person centred care
2 findings
moderate“Inconsistency with people's preferences with personal care had not been recorded...they may not receive personalised care.”
moderate“Care plans had not been completed for people with dementia to include their level of dementia and how support can be personalised to ensure they received person-centred care.”
staffing levels
2 findings
critical“Staff were not being given time to travel in between appointments, which meant that they would be late for calls.”
critical“The registered provider was not deploying sufficient numbers of staff to ensure people received support in a timely manner. Regulation 18(1).”
communication with families
2 findings
moderate“There is little communication between the office and us. We are not contacted if carers are running late.”
moderate“The carers do not speak English and I cannot understand them, so they just point at me to move my arm, leg, body etc when washing and dressing me.”
consent capacity
1 finding
critical“MCA assessment had not been completed to determine if the person had capacity to ensure decisions were made in their best interests and as least restrictive as possible.”
complaints handling
1 finding
moderate“complaints had not been analysed to identify potential trends and to ensure improvements can be made to the service and minimise risk of reoccurrence.”