critical“MAR charts we reviewed did not meet national guidance and there were numerous instances of missed medications where staff had not given an explanation.”
staff training
1 finding
critical“Not all staff had been trained in national guidance mandatory subjects. This included communication, nutrition and hydration, oral health, person-centred care.”
staff competency
1 finding
critical“Staff's competency was not checked before they administered medication on their own. One staff who's first spot check was poor...had this check nearly a month after.”
governance
1 finding
critical“The provider did not have an effective system in place to monitor the overall quality of the service...no regular detailed audits.”
safeguarding
1 finding
critical“Although the provider had raised safeguarding's with the local authority they had failed to notify CQC as required.”
record keeping
1 finding
critical“Failures to monitor and improve the quality and safety of the service, and failure to maintain accurate records was a breach of Regulation 17.”
supervision appraisal
1 finding
moderate“Staff supervision and support was inconsistent and did not meet the needs of all staff. One staff member told us, 'I think we should have more supervisions.'”
missed or late visits
1 finding
moderate“The provider had not had a robust system in place to reduce risks to people from missed or late calls, although improvements were being made.”
incident learning
1 finding
moderate“Although incidents were logged against individual people and dealt with there was not an overall process in place to learn from these.”
consent capacity
1 finding
moderate“Evidence of people's consent to care was not documented in their care plans...the registered manager was unable to provide us with evidence of consent.”