critical“Care plans did not always detail risk to people's individual needs and guidance on how staff should support them.”
medication management
1 finding
critical“On the first day of our inspection, the manager told us that there were no medication administration records (MARs) in place and in use.”
staffing levels
1 finding
critical“10% are more than 45 minutes late. This meant some people had not received their care as scheduled or planned.”
missed or late visits
1 finding
critical“A relative phoned at 10:26am to inform the manager that their carer had not turned up to their 09:30am call.”
staff training
1 finding
critical“Staff had not been trained in diabetes, catheter care, Parkinson's disease and epilepsy despite providing care and support to people with these conditions.”
staff competency
1 finding
critical“Staff received moving and handling training through an online course, this meant that they did not practice using equipment as part of their training.”
supervision appraisal
1 finding
moderate“Staff did not meet with the management team to discuss their personal development or support they needed. There were no records of supervisions carried out.”
consent capacity
1 finding
critical“The provider failed to follow the principles of the Mental Capacity Act 2005. Capacity assessments had not always been completed.”
incident learning
1 finding
critical“The manager told us there was no accident and incident records... There had been no learning from accidents and incidents.”
governance
1 finding
critical“Audits and checks had not been taking place by the provider or the manager... The provider could not demonstrate continuous learning and improvement.”
safeguarding
1 finding
critical“Safeguarding concerns had been reported to the local authority in relation to allegations of neglect. However, the provider had not recognised that CQC needed to be informed.”
person centred care
1 finding
critical“People had not been involved in developing their care plans. There was little personal information about people in their care records.”
complaints handling
1 finding
critical“The agency had received 9 complaints since it started... We found no records/logs of complaints received and how these were responded to.”
end of life care
1 finding
moderate“At the time of our inspection 1 person was at end of life. Care plans did not contain information in relation to the care and support people wished to receive at end of life.”
record keeping
1 finding
critical“Records were inconsistent and did not include a complete, accurate and contemporaneous record of care needs.”
leadership
1 finding
critical“The service was required to have a registered manager in post. The previous registered manager had left in January 2023. No applications to register a new manager had been received by CQC.”