critical“The provider did not complete any audits or checks to ensure people received their care in line with the aims and values of the service.”
moderate“The provider continued to be heavily reliant on the registered manager to assess the quality and safety of the service. The provider did not undertake any audits or checks.”
minor“At the time of our visit, the rating for the service was not available on the provider's website as required. The display of the rating is a legal requirement.”
care planning
2 findings
moderate“Some care plans lacked detail to help staff to provide person centred care...one person's care plan stated, 'prepare breakfast and feed [person].'”
minor
“Two care plans we reviewed lacked minor detail to ensure care was provided consistently. The registered manager took immediate action to address this.”
incident learning
1 finding
moderate“Lessons had not been learnt when things had gone wrong...incidents were not analysed to identify any patterns or trends.”
missed or late visits
1 finding
moderate“Between 1 and 30 September 2018 one person had received 120 care calls but only four of the 120 calls had been logged correctly by staff.”
staff training
1 finding
moderate“Staff members told us they had not been sufficiently supported to complete training. One staff member told us, 'I haven't done any training for quite a while.'”
staff competency
1 finding
moderate“Checks to ensure staff put their training into practice and checks to make sure they were competent to carry out their roles...were not completed.”
medication management
1 finding
moderate“People's completed medication administration records were returned to the office each month but documented audits to check people had received their medicines safely did not take place.”
record keeping
1 finding
moderate“Accurate and up to date records of when staff had completed their training were not maintained. The general manager said, 'We need a proper matrix for that and we don't have one.'”
consent capacity
1 finding
moderate“A mental capacity assessment had not been completed to determine what decisions the person could make for themselves.”
complaints handling
1 finding
minor“A relative explained they had been dissatisfied with how the provider had handled...a complaint raised in February 2018. They said, 'We never even got an apology.'”
supervision appraisal
1 finding
minor“Since starting work at the service in July 2017 the registered manager told us they had not had opportunities to discuss their performance...with the provider.”
communication with families
1 finding
minor“Some staff felt communication between them and their managers needed to improve because their requests for support were not always responded to promptly.”