critical“1 person had no care plan at all when we visited them. A person told us they did not have a care plan.”
medication management
1 finding
critical“For 1 person there was no Medication Administration Record (MAR) in place. Staff confirmed they administered medicines for this person.”
record keeping
1 finding
critical“People's risk assessments were not always in place in people's homes. This meant staff did not have information to refer to around people's risks.”
staffing levels
1 finding
critical“The provider had failed to ensure they had completed new DBS checks for 2 care staff relying on DBS checks from a previous employer.”
governance
1 finding
critical“Auditing systems had failed to identify the issues around risk assessing, medicines management, staff recruitment and care planning found during the inspection.”
safeguarding
1 finding
moderate“We found safeguarding concerns had been notified to the local authority but there had been a failure to report these to CQC.”
incident learning
1 finding
moderate“Notifications were not submitted as required to CQC... We had also raised this with the registered manager in September 2023 prior to this inspection.”
person centred care
1 finding
moderate“Care planning was inconsistent. Another person had a care plan which just contained information provided by the local authority.”