moderate“Care plans and risk assessments did not always contain guidance for staff to follow when people expressed distress or agitation.”
critical“One person required catheter care and there were no details of this in their care plan. Another person's care plan did not provide guidance for care staff on what to do should they not be able to obtain a blood sugar reading.”
governance
2 findings
critical“Systems and processes to ensure quality performance, risks and regulatory requirements had not always been effective.”
critical“Systems to assess, monitor, improve service quality and care delivery and identify and reduce risks were not operated effectively. Records were not always accurate, complete or contemporaneous.”
incident learning
2 findings
critical“Whilst some statutory notifications had been submitted to CQC, we found other notifiable incidents had not been reported since our last inspection.”
moderate“The registered manager told us this was not recorded in a way that allowed it to be reviewed for trends, themes and lessons learnt.”
record keeping
2 findings
moderate“A large number of the files we requested to see on the day of our inspection were unavailable. These were sent to us later in the week for us to review.”
critical“People's individual care plans, care records as well as staff records, and spot checks contained other people's names. Records were not always accurate or complete.”
leadership
2 findings
moderate“The provider did not as yet have a fully supported management structure. The provider's systems did not always effectively monitor the quality of care provided.”
moderate“The provider had no effective systems in place to manage the service in the absence of the registered manager.”
staffing levels
1 finding
critical“Care rotas did not demonstrate there were enough staff to meet people's needs at their scheduled times. Records showed staff were scheduled to provide care to more than one person at the same time.”
safeguarding
1 finding
critical“They had not recognised a significant pressure sore would require reporting to the local authority safeguarding team. There was a risk people may be exposed to potential risk and harm.”
staff training
1 finding
critical“One staff member told us they had not received any training in learning disability care or catheter care despite the training matrix recording they had recently received training in this.”
staff competency
1 finding
critical“Records showed all areas had been completed in one day, including completion of all 15 minimum standards of the Care Certificate.”
complaints handling
1 finding
critical“There was no complaint's log in place. This meant there were no response times, investigation details or outcomes recorded in a complaint's log for us to review.”
medication management
1 finding
critical“Some MAR charts had not always been completed in line with the provider's good practice policies for medicines management. Information on allergies, the dosage of some medicines and when medicines had been stopped had not been recorded.”
missed or late visits
1 finding
moderate“Almost all relatives commented on the lateness of care calls. One relative told us they felt staff were often rushed and continence pads were not always checked.”
infection control
1 finding
moderate“The registered manager was aware not all staff wore aprons when providing personal care. People told us staff did not always wear facemasks as required in line with government guidance.”