critical“Records we reviewed showed some visits were two hours later than planned, and as short as 10 minutes, which were not in accordance with the contracted package of care.”
care planning
1 finding
critical“One person had missing risk assessments which included medicines management, personal care, moving and handling and risk of malnutrition and dehydration.”
staff training
1 finding
critical“The training matrix did not list training about mental capacity, and there was no evidence of catheter awareness training.”
staff competency
1 finding
critical“Some staff did not have the knowledge and competencies required to effectively provide support to people. This was a breach of Regulation 18.”
consent capacity
1 finding
critical“The provider had not documented who was able to make decisions for themselves, and who required best interest decision making. This was a breach of Regulation 11.”
governance
1 finding
critical“The service did not always effectively assess, monitor and improve the quality and safety of the service. This was a breach of Regulation 17.”
leadership
1 finding
critical“There was a rapid turnover of managers at the service... the service had no manager registered and no application was received.”
safeguarding
1 finding
moderate“A staff member we spoke with was not aware of 'self-neglect' as a type of abuse... This had not been identified by the service prior to inspectors raising the potential increased risk.”
supervision appraisal
1 finding
moderate“The nominated individual told us at the site visit no one was responsible for completing spot checks or supervisions with staff.”
record keeping
1 finding
moderate“Personnel files did not always contain all of the required information which must be in place at the point of staff employment to ensure only 'fit and proper' persons provide personal care.”
person centred care
1 finding
moderate“Person centred language was not always used in people's daily notes... Most of the notes were focused on the tasks that were completed with little to no information about the person's physical, emotional or social wellbeing.”
end of life care
1 finding
moderate“There was a lack of information on file for people's end of life preferences... Section one of the DNACPR 'discussed with person/relevant other' was left blank.”
medication management
1 finding
minor“Some staff had competency assessments. We advised the nominated individual that staff required competency checks completed by a competent assessor.”
complaints handling
1 finding
minor“It also provided CQC contact details to share concerns but did not provide information about people's right to complain to an Ombudsman.”
cultural competency
1 finding
minor“There was no information about whether the service tried to match same language speaking staff or having the written care plan translated in order for the person to understand their care plan.”