critical“Records relating to people's risks and care needs were incomplete and contained misleading information. As a result, staff did not receive all the information and guidance they required.”
minor“Some areas of care planning lacked some detail in regard to people's life history, preferences, and likes and dislikes.”
communication with families
2 findings
minor“The provider had not always ensured all people were kept informed of which staff would be attending their care visits and at what time.”
minor“Some people told us that at times, communication with staff was not always easy because of language barriers.”
governance
1 finding
critical“There was a lack of oversight and governance systems to ensure people received a safe service. Systems that were in place were not implemented effectively.”
missed or late visits
1 finding
critical“Carers are due at 8.00am but sometimes can be as late as 9.30am which impacts on my commode use. The regular carers are on time, it's the relief staff who can be late.”
staffing levels
1 finding
moderate“Staff were working very long days with only short breaks and very few days off to rest. The management set the bar too high for them and their schedules need looking at.”
consent capacity
1 finding
moderate“Where it was deemed people lacked capacity, best interest decisions had not always been recorded.”
complaints handling
1 finding
moderate“Records did not provide a clear account of the action taken in response to complaints people had made.”
record keeping
1 finding
moderate“One person's care plan described three different ways in which they were supported to move... care plans contained information about people's previous needs.”
end of life care
1 finding
minor“Staff had not received training in end of life care. People had not been given the opportunity to record what was important to them at end of life.”
staff competency
1 finding
moderate“Some people told us that when their regular staff were not available, the staff who replaced them did not appear as skilled and they had difficulty communicating due to a language barrier.”