critical“Care plans contained a lack of information to guide staff in managing the risks in relation to people's catheter care, falls and prevention of pressure wounds.”
moderate“Moving and handling care plans were not always sufficiently detailed to guide care staff in the equipment needed and the specific support people needed with their mobility needs.”
staff training
2 findings
critical“there was a lack of training for staff in meeting the needs of people with catheter care, dementia care and meeting the needs of people with complex health conditions such as Parkinson's Disease”
critical“staff were not provided with training in understanding their roles and responsibilities in relation to the Mental Capacity Act (2005) MCA.”
consent capacity
1 finding
critical“Care and risk management planning did not include an assessment of people's mental capacity. There was a lack of understanding of how MCA should be implemented in practice.”
staff competency
1 finding
critical“One newly employed member of staff supporting people with their mobility transfers, using equipment such as a hoist told us they had not been provided with practical moving and handling training”
record keeping
1 finding
moderate“We noted the provider's training matrix recorded this member of staff as having attended this training when this was not the case.”
incident learning
1 finding
moderate“there was no system in place which would ensure oversight with management analysis to identify patterns and trends with actions to reduce the likelihood of a reoccurrence.”
governance
1 finding
critical“Systems were either not in place or robust enough to demonstrate effective oversight and governance of the service. This was a breach of Regulation 17 (Good Governance)”
other
1 finding
critical“Recruitment checks had not been completed on all new staff to check their suitability or competence to work with vulnerable people prior to commencing employment.”
staffing levels
1 finding
moderate“They [management] do their best to make sure we receive consistent carers, but there just isn't enough staff. The staff don't stay long working for the agency before they leave.”
communication with families
1 finding
moderate“Care plans lacked detail about people's communication needs and how best to communicate with them.”
person centred care
1 finding
moderate“Care plans reviewed had not been updated since the service was registered with CQC and still referred to the previous owner of the service.”