critical“I never know if they [staff] are coming or not and that means I often don't have anything to eat.”
missed or late visits
1 finding
critical“Staff rostering records showed care staff were sometimes scheduled to attend more than 1 person's care call at the same time.”
safeguarding
1 finding
critical“The omission to provide this person's commissioned care had not been reported to Social Services under safeguarding procedures as required.”
medication management
1 finding
critical“Some people took medicines 'as required', including morphine and paracetamol. There was a lack of PRN protocols as required to guide and inform staff.”
care planning
1 finding
critical“A person's environmental risk assessment and the risk assessment for their outside wheelchair were empty.”
staff competency
1 finding
critical“Overseas staff had a criminal records check from their country of origin, but not a Disclosure and Barring Service (DBS) check as required.”
governance
1 finding
critical“The provider had failed to submit statutory notifications to inform CQC of 2 safeguarding incidents.”
record keeping
1 finding
moderate“Staff had not recorded the outcome of people's MCA 2005 assessments and best interest decisions, as per good practice guidance.”
consent capacity
1 finding
moderate“Staff did not document the evidence they reviewed when they checked if people had a registered power of attorney.”
person centred care
1 finding
moderate“They [staff] just talk their own language over the top of me and even do sign language if they think I'm not looking.”
infection control
1 finding
moderate“Three people reported staff did not always wash their hands when providing their care.”
incident learning
1 finding
moderate“There was no incident record for this missed call and the omission to provide this person's commissioned care had not been reported.”
communication with families
1 finding
moderate“People did not all report they felt listened to. Feedback included, 'They [staff] don't listen and don't want to help.'”
leadership
1 finding
moderate“The registered manager, who was also the provider, did not understand all the legal requirements.”