critical“The provider was not able to provide documentation of any investigation or action taken to understand what had happened and why, to help prevent a recurrence.”
minor“Some 'near miss' incidents were not being recorded by staff. This was discussed with the managers at the time of the inspection.”
care planning
1 finding
critical“the impact of the health conditions, such as Parkinson's disease, and Epilepsy were not expanded upon. One person was being nursed in bed, yet there was no plan in place”
medication management
1 finding
critical
“18 gaps in the signing of one person's blood thinning medication in the month of October 2022. This meant the provider could not be assured people were receiving their medicines”
missed or late visits
1 finding
moderate“there had also been some missed visits, including four in October 2022...One person told us, 'It's all the time that they seem to scrabble to get here.'”
staffing levels
1 finding
moderate“There were staff shortages and people's care visits were not always easily covered. This was particularly so at weekends and at times of staff sickness and annual leave”
staff competency
1 finding
critical“A lot of staff don't know how to use the hoist. I have to show them. They'll say they've had manual handling training, but that they haven't seen this type before.”
staff training
1 finding
moderate“Not all staff had received refresher training in the safe administration of medicines...Staff had also not had their competency assessed to show they were able to safely administer people's medicines.”
safeguarding
1 finding
critical“There had been two separate incidents of theft of people's monies...Staff told us they had received safeguarding training, but records showed such training was out of date for many.”
governance
1 finding
critical“Systems were not in place to effectively assess, monitor and improve the quality and safety of the service...breach of regulation 17 of the Health and Social Care Act 2008”
record keeping
1 finding
moderate“The terminology within some people's daily records was at times disrespectful...included, '[Person] wasn't himself and was kinda aggressive'”
leadership
1 finding
moderate“The provider did not have a deputy or care manager so was finding both roles of registered manager and provider, a challenge...impacted on their management oversight”
complaints handling
1 finding
minor“There was no formal documentation to record any complaints made. We discussed this with the manager who told us this process would be in place.”
end of life care
1 finding
minor“The service had no end of life care plan templates in place...This was discussed with the managers at the time of the inspection and appropriate end of life care plan templates were sought.”