critical“Risks were identified in people's care plans, but there was limited information about how to keep people safe...staff felt they were going in 'blind'.”
medication management
1 finding
critical“Two forms did not include the person's full name and one form identified them as the wrong gender...safe and proper management of medicines had not taken place.”
infection control
1 finding
critical“Most staff we spoke with had not received formal training in relation to donning and doffing personal protective equipment (PPE) since the beginning of the COVID-19 pandemic.”
governance
1 finding
critical“The provider had developed a new quality assurance framework...The framework was only partially completed at the time of our visit.”
leadership
1 finding
critical“The registered manager was not visible to frontline staff...Some staff we spoke with had not heard of the registered manager.”
staff training
1 finding
critical“Annual moving and handling training was either incomplete or had elapsed for 22 of the 27 reablement assistants who delivered care in people's homes.”
supervision appraisal
1 finding
moderate“The process of yearly direct observations had lapsed, meaning some staff had not been observed by a supervisor since early 2019.”
consent capacity
1 finding
critical“People's assessments and care plans did not clearly document the assessor's view of the person's mental capacity, where people were living with memory impairment or confusion.”
person centred care
1 finding
moderate“We identified 11 care plans where the person receiving support was described as 'client' or 'SU'...assessments lacked a holistic picture of the person.”
incident learning
1 finding
critical“There was no evidence effective or embedded systems were in place to analyse themes and trends from accidents and incidents, concerns and complaints and safeguarding concerns.”
complaints handling
1 finding
moderate“There was no central record of concerns raised and informally resolved by the service...the registered manager and provider did not have oversight of concerns.”
record keeping
1 finding
moderate“People's care plans often contained blank spaces where information such as people's preferred name, ethnicity, language or religion would be recorded.”
safeguarding
1 finding
moderate“Some staff had not completed safeguarding adults refresher training in line with the provider's policy...templates to record safeguarding concerns were not in use.”
end of life care
1 finding
minor“The end of life policy did not highlight the importance of holistic support for people and families at end of life.”
cultural competency
1 finding
moderate“We identified 15 care plans where the person's religion had not been documented, and six care plans where the person's ethnicity was absent.”
communication with families
1 finding
moderate“One person commented, 'I have no idea who the manager is or what they are called'...management of the service was not inclusive or easily accessible.”