minor“records of alerts made to the local authority and notifications sent to CQC were not stored together”
critical“one person's application form was missing...A reference from a previous employer had not been obtained...breach of Regulation 19.”
care planning
2 findings
minor“some of the assessments with regards to skin integrity, nutrition and mobility, needed further detail to ensure any changes to people's health and wellbeing were promptly recognised”
moderate“some risk assessments were lacking in detail...lack of routine assessing of risks associated with skin integrity, malnutrition and falls, in accordance with current recognised guidance.”
medication management
2 findings
minor“medicine management procedures needed to be further developed to reflect current practice...some gaps in the recording on the old system”
moderate“hand written entries on the MAR charts had not been counter signed as correct...gaps on one MAR chart which meant it was not clear if the person had been supported with their medicines.”
staff competency
2 findings
minor“'shadowing' arrangements for new staff were not clearly recorded and did not demonstrate that their competence was assessed prior to working unsupervised”
moderate“'shadowing' arrangements for new staff did not include a structured assessment of their competence in their role prior to working unsupervised.”
governance
2 findings
minor“systems to monitor the manager's practice and the day to day running of the agency were not formalised and did not fully evidence the provider's oversight of the service”
critical“lack of the quality monitoring and auditing processes to ensure the service is operated safely and effectively...breach of Regulation 17 of The Health and Social Care Act 2008.”
person centred care
1 finding
minor“people's preferences for male or female staff support, ethnicity and sexual orientation was not recorded in their care documentation which meant people's needs may not be fully met”
safeguarding
1 finding
critical“We found there were no records kept of the matters raised, however during the inspection the registered manager introduced a process to support the recording, managing and responding to safeguarding incidents.”
staff training
1 finding
critical“gaps in the records which indicated staff had not completed the provider's mandatory training programme...lack of training in manual handling, safeguarding people, medicines management and MCA 2005.”
complaints handling
1 finding
critical“no information to demonstrate how the complaints had been investigated, followed up and responded to...no records of acknowledging receipt of the complaints.”
consent capacity
1 finding
minor“staff spoken with indicated a lack of awareness of the MCA and said they had not yet accessed the training.”
incident learning
1 finding
moderate“no processes in place to monitor and assess complaints, the action taken and lessons learned to make improvements...no records of management meetings being held.”