moderate“a safeguarding concern that was being investigated by the local authority had not been notified to the CQC”
critical“The current systems in place were not robust enough to assess, monitor and improve the quality and safety of the services being provided to people.”
critical“the provider had not sustained improvements in terms of the quality monitoring that were observed at our last inspection.”
critical“The provider's quality assurance systems were not effective; their internal monitoring and audit process's had not identified the issues we found at this inspection.”
moderate“systems for assessing and monitoring the quality and safety of the services provided have improved, but have not been operational for a sufficient amount of time for us to be sure of consistent and sustained good practice.”
critical“A lack of effective quality assurance systems is a breach of Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
medication management
6 findings
critical“MAR sheet showed there were gaps between the 22/1/2018 and 12/2/18 but there were no details of the reasons why.”
critical“medicines competency assessments were not in place to ensure staff were assessed as competent to support people with their medicines.”
critical“Medicines were not monitored in line with the provider's medication policy and procedure.”
moderate“The acting manager confirmed that monthly medicines audits were not being carried out.”
critical“processes to administer medicines did not always follow recommended guidance...records were in the process of being created they were not in place for each person who was supported with their medicines”
moderate“apart from the induction training none of the staff had received any further training medicines assistance”
missed or late visits
6 findings
critical“One day nobody came until 7pm in the evening. I was waiting all day. It frightened me when they did come in that late as they used the key safe and just came in.”
critical“on the 30 May, the report showed a planned visit from 10am until 10.45, however the entry showed staff arrived at 10.42 and finished at 10.51, which is less than 10 minutes for a 45 minute call.”
critical“Monday of this week they forgot me altogether and Tuesday and other days they have been different times and different carers. I managed with the help of my wife on Monday.”
critical“On 3/2/2020 a person was scheduled a call from 8.35am to 9.05am. However, call monitoring records showed they were visited from 10.36am to 10.53am. Staff were late by over 2 hours.”
critical“The provider's systems for monitoring late or missed calls were not effective.”
moderate“The provider failed to identify calls that were late, missed, early or shortened. The service did not take appropriate actions to log on a daily basis why care staff had either arrived late.”
record keeping
5 findings
minor“The log did not record the times of the calls or the names of the members of staff concerned so it was not possible to understand if these were two different instances”
critical“They fill in the book as if they have finished. What if [person] was to fall or something happened during the visit. It just isn't right.”
critical“They should be here for an hour in the morning and they were here for 30 minutes but logged 50 minutes… they write 30 minutes and they log incorrect times.”
critical“The sixth member of staff continued working, despite their residence permit to live in the United Kingdom has expired in January 2020.”
moderate“Care files were not always well organised, easy to read and complete… did not always accurately reflect people's current needs.”
leadership
4 findings
moderate“The service did not have a registered manager in post... The manager told us they were due to leave the service the day after we inspected.”
moderate“There was no registered manager in post.”
moderate“The service did not have a registered manager in place. The operations manager told us they were in the process of recruiting a new registered manager to run the service.”
moderate“The registered manager had not managed the service on a day to day basis since April 2017… the provider had not done so [notified CQC].”
person centred care
4 findings
moderate“People experienced a lack of consistency in the care they received and were not aware of which staff member was coming to support them as they were not routinely informed.”
critical“He had a very rude attitude and even threw [person's] dirty pads and dirty pyjamas all over the carpet.”
moderate“People's care was not delivered in line with their care plans. My relative needs to take tablets after food. They give after tea and help get ready for bed and my relative doesn't want that at 5.30pm.”
moderate“The way staff talk to me is horrid. One of the carers even tells my loved one to hurry up. The carers have even banged their way out of the house a couple of times.”
care planning
3 findings
moderate“systems and processes that have been implemented have not been operational for a sufficient amount of time for us to be sure of consistent and sustained good practice”
critical“It was not clear which care plans were being used to reflect the actual care people required and due to the different formats being used risks to people were also not being appropriately identified.”
critical“Care plans were not kept up to date. There was no clear guidance or information provided to staff on how people's care needs had changed.”
incident learning
3 findings
minor“the provider's new incident and accident form was not being used by the branch. A recommendation was set to ensure that the form was put in place as soon as possible.”
critical“Accidents and incidents were not being recorded and monitored.”
critical“We checked the providers accidents and incidents file and found there had been no accidents and incidents recorded since August 2016.”
communication with families
3 findings
moderate“They listen and they say they are very sorry, but never ring you back and don't address the issue raised.”
moderate“There were no communication record for all late calls, to show the office staff had informed people when staff were running late to their scheduled home visits.”
minor“The on call system needs to be sorted out as it sometimes takes a long time to get through to someone...It's difficult to get through to the agency at weekends.”
staffing levels
2 findings
critical“There insufficient numbers of suitable staff deployed to keep people safe and meet their needs.”
critical“Staff rostering records showed staff were not always given enough time to travel in-between the calls, which impacted on their ability to arrive promptly or stay the full time with people.”
staff competency
2 findings
moderate“The new carers do not shadow experienced staff and are not properly introduced, my relative has to show the carers what to do.”
moderate“The acting manager and some staff we spoke with did not have a clear understanding of the providers safeguarding adult's procedures.”
safeguarding
2 findings
critical“complaints, safeguarding and missed visited were not in place, in line with the provider's policy.”
critical“The provider's procedures for reporting safeguarding concerns to the local authority were not always being followed appropriately.”
supervision appraisal
1 finding
moderate“records showed these [spot checks] were not conducted on a regular basis. For example, in one person's care plan, the last spot check was conducted on the 23/11/17.”
cultural competency
1 finding
minor“They will speak in their own language to each other which makes us feel uncomfortable as it's clear they are saying things they don't want us to understand.”
complaints handling
1 finding
critical“People and their relatives were not happy with the way their complaints had been managed... I sent the manager an email complaint. I wasn't happy with their response and I'm still waiting for them to get back to me.”