critical“one person's falls risk assessment dated 1 February 2018 stated that the person had had no falls in the previous year...We found that this person had a significant fall on 10 January 2018”
moderate“Records did not always provide consistent or complete guidance in how to meet the person's needs.”
staffing levels
2 findings
critical“We were not assured that this level of staffing ensured enough flexibility to cope with a sudden absence of a key member or members of staff.”
moderate“risks for staff, which could impact on the person's care, had not always been formally assessed... working with one person for long periods without a break.”
medication management
2 findings
moderate“We found no accurate stocktaking which meant we could not check to see if people had received the correct amounts of medication.”
moderate“Records did not always provide consistent guidance about how to administer the persons medicines... there was still insufficient guidance in place for new staff to follow”
governance
2 findings
critical“three people had had falls in the last year that needed attendance at A & E...The provider had failed to notify us of these serious injuries”
critical“The provider had failed to ensure that they operated effective systems to assess, monitor and mitigate the risks relating to people's health, safety, and welfare.”
record keeping
2 findings
moderate“information, such as that about recent falls or involvement of healthcare professionals had been archived...files were stored in the garage which meant we could not be assured of the security”
moderate“Records were not consistently completed... there were no records of the times each staff member had provided care to the person.”
incident learning
2 findings
critical“There was no evidence that the provider fully investigated incidents and learned from them to drive improvement as we found concerns at this inspection mirrored those we had found previously.”
moderate“The registered manager and nominated individual did not demonstrate learning from previous events... They had not applied this learning to the person receiving care during this inspection”
leadership
2 findings
critical“The provider was not always open, honest and transparent...Sometimes we identified concerns and key information by chance when looking at other matters.”
critical“The continued breach of Regulation 17 demonstrates to us that the nominated individual and registered manager continue not to have an understanding of their roles and responsibilities.”
safeguarding
1 finding
critical“the provider had only recently made this referral in January 2018 when the issue was identified during our August 2017 inspection. This did not demonstrate a proactive approach to safeguarding”
staff training
1 finding
moderate“one person had last had moving and handling training 11 November 2015. One member of staff only had a multi topic certificate issued by the provider on 23 March 2017.”
supervision appraisal
1 finding
moderate“supervision of staff, especially live-in staff, was very infrequent...We saw very few records of staff supervision and no recorded sessions for some staff.”
complaints handling
1 finding
moderate“a formal complaint from a healthcare professional had not been investigated...The provider failed to carry out a timely investigation into a complaint made by a healthcare professional.”
person centred care
1 finding
moderate“We found no information relating to people's religious or cultural needs...One person's plan did not mention that the person considered themselves both deaf and blind.”
staff competency
1 finding
moderate“live-in carer told us about their condition but they did not know what it was and could not tell us if anything made the condition better or worse.”
infection control
1 finding
moderate“The registered manager and the care co-ordinator had both visited the person's home without first testing for COVID-19. This put the person at risk of contracting COVID-19.”
end of life care
1 finding
minor“The person's care plan contained no information about their preferences for their end of life care... Staff told us they had not had training in end of life care.”