critical“No risk assessments or care plans had been completed for one person using the service, which meant staff had no written guidance on how to safely meet their needs.”
moderate“some risk assessments lacked sufficient detail to guide staff how to safely support people”
moderate“further improvements in the consistency of guidance across risk assessments and care planning was required, in order to further reduce risks to people”
critical“Care plans were not in place for known health conditions to provide staff with the information they needed to mitigate risk and meet or respond to people's needs.”
medication management
4 findings
critical
“People's medicines were not always managed and administered safely to ensure they were not placed at risk.”
critical“the provider had failed to ensure accurate and up to date information regarding people's medicines was made available to staff”
moderate“further action was required to ensure staff were consistently provided with the information needed to support individual people... guidance to advise staff how they would know if people wanted 'as and when required' medicines”
critical“MAR... did not include all medications prescribed for people using the service. This meant care staff did not have accurate records to refer to, ensuring they were giving the correct medication”
governance
4 findings
critical“The provider had failed to implement effective systems to assess, monitor and improve the service... This was the provider's fourth consecutive rating of requires improvement or inadequate”
critical“The provider had failed to implement robust audits and monitoring systems. This was a continued breach of regulation 17 (Good Governance)”
critical“The provider had failed to implement robust audits and monitoring systems. This was a continued breach of regulation 17 (Good Governance)”
critical“There continued to be a lack of provider oversight which meant risks to people's safety had not been identified and responded to appropriately.”
leadership
4 findings
critical“There was no registered manager in post at the time of the inspection and no registered manager had been in place since February 2021.”
moderate“no registered manager had been in place since February 2021”
moderate“There was no registered manager in post at the time of the inspection.”
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.”
record keeping
4 findings
moderate“Some staff we spoke with were not aware how to access people's care plans and lacked understanding of what these contained.”
moderate“Two people's care records also contained contradictory information about their risk of choking and how staff were to support them to eat safely”
minor“We found not all the initial DBS checks undertaken by the provider with staff had been recorded.”
critical“failed to identify there was a lack of information in care records, such as the support people needed especially with known health conditions.”
incident learning
3 findings
critical“We were not assured the provider had consistently recorded, analysed or acted on incident and accidents to reduce harm to people.”
critical“we identified 84 such incidents which had not been reviewed by the provider for over one week. In addition, the provider had failed to analyse patterns and trends”
moderate“systems needed to be developed to ensure the provider was able to review safeguarding, accidents and incidents... to identify any patterns and maximise opportunities for taking learning from these”
staff training
3 findings
critical“We found multiple staff had gaps in their training record, including safeguarding, first aid, mental health awareness and medicines training.”
minor“we found some staff still had not had the opportunity to access some specific training, such as Parkinson's disease”
moderate“Moving and handling training for staff was identified as needed at the last inspection. However, this had still not been provided”
staff competency
2 findings
critical“The provider had not adhered to safe recruitment practices. This placed people at risk of being supported by unsuitable staff.”
critical“Two suitable references had not been obtained prior to care staff members commencing work... did not follow their own recruitment policy or adhere to regulations”
infection control
2 findings
critical“The provider had failed to follow current government advice regarding COVID testing of staff. This placed people and staff at increased risk of increased transmission of COVID-19.”
moderate“these did not always refer to the individual's known health conditions to assess the risk to each person... They also did not refer to care staff wearing Personal Protective Equipment (PPE).”
consent capacity
2 findings
critical“The provider was not working in line with the principles of the MCA. They were unable to evidence that people's rights under the MCA were being protected.”
moderate“systems for confirming who had legal rights to make some decisions on people's behalves required further development, to ensure people's rights were fully promoted”
complaints handling
2 findings
moderate“I told [the provider] that I was not happy [with the care their relative was receiving]. [The provider] just said. 'If you want to complain then complain.'”
moderate“The provider told us they had not received any complaints... they had received calls from people using the service to raise concerns... did not want to record these as a formal complaint.”
safeguarding
1 finding
critical“Following the inspection, we raised a safeguarding concern to the local authority for a person regarding the care they received. The provider had failed to identify or report these concerns”
supervision appraisal
1 finding
moderate“Staff did not always receive regular supervision to monitor and reflect on their practice... There were no records of supervision in staff files.”
person centred care
1 finding
moderate“Assessments completed for people were very basic and did not incorporate key information, such as their life history, wishes, preferences or protected characteristics”
communication with families
1 finding
moderate“We received mixed views from relatives about the effectiveness of their communication with staff and management.”
other
1 finding
moderate“Care records did not evidence the provider had liaised with external healthcare professionals to support treatment of the skin condition”
missed or late visits
1 finding
moderate“We requested call records... These records had not been provided within the set timeframe, so we were unable to review if calls were the length they were commissioned for”