moderate“we found 1 care plan of the 8 we reviewed had not been updated to reflect a fall by the person.”
moderate“The falls risk assessment for one person indicated their last fall was in January 2020. However, we found an incident form indicating they had a fall in October 2021 which was not reflected”
governance
2 findings
minor“although complaints were responded to appropriately, the provider was not following their own procedures in terms of recording complaints.”
critical“Quality assurance systems such as audits were not being operated effectively as demonstrated by the number of shortfalls identified during the inspection.”
missed or late visits
2 findings
minor“some people telling us their care workers sometimes arrived late that they were not always notified if staff were running late.”
critical“Care workers were not always appropriately deployed to help ensure care visits were carried out as planned.”
medication management
1 finding
critical“Medicines were not always managed safely... One person had a PRN medicine prescribed but it was not listed on the medicines administration records (MAR).”
care planning
1 finding
critical“when a risk was identified, care plans did not always provide adequate guidelines for care workers to meet the person's needs and reduce the risk of harm.”
staffing levels
1 finding
critical“one care worker had 33 calls that week and 22 of them did not have travel time. This meant people might not have received the care they needed in a timely manner”
consent capacity
1 finding
critical“Where it was indicated a person may not have capacity to consent to their care, a mental capacity assessment or a best interest decision had not been carried out.”
leadership
1 finding
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
staff training
1 finding
moderate“for key training such as dementia awareness, safeguarding adults, medicines awareness and infection control training, only 68% of care workers had up to date training in these areas.”
person centred care
1 finding
critical“Care plans were not always personalised to indicate people's current needs and wishes.”
cultural competency
1 finding
moderate“I don't feel that our culture is really respected properly by the weekend carers”
infection control
1 finding
moderate“they did not have COVID-19 risk assessments in place for care workers. COVID-19 risk assessments for people using the service were not robust enough”
end of life care
1 finding
moderate“The care plans for eight out of nine people whose care plans we looked at regarding end of life care, recorded the person did not want to discuss their end of life wishes.”
communication with families
1 finding
moderate“messages left at the office did not always get passed on to the relevant person”
other
1 finding
critical“two applicants did not have any record of a criminal record check being carried out... two applicants did not have two references in line with the provider's own recruitment procedures”