critical“Systems had not been established to assess, monitor and improve the safety and quality of the service. This was a breach of regulation 17(1) of the Health and Social Care Act 2008.”
minor“systems to record audits which had been undertaken required further documentation.”
moderate“There was no formal documentation of audits... the care coordinators told us they went out to visit people...to monitor the quality of care delivery...This was not documented.”
record keeping
3 findings
moderate“There were no governance systems to ensure medicines, call times, risk management and care planning checks were taking place.”
moderate
“some records had gaps where staff should have signed. We raise this with the registered manager who was already in the process of looking into this.”
moderate“the audits that were undertaken were not always formally documented to evidence what had been identified, what required attention and who was responsible”
medication management
2 findings
moderate“Staff had not received up to date medicines training or had an assessment of competency. There were no audits taking place of medicines to ensure they were being administered safely.”
moderate“medicines were not always recorded following the procedure. The staff had recorded in the daily records but had not always completed the medication administration record”
staff training
1 finding
moderate“There was no effective system to identify when staff required up to date training or to show the level of compliance with training.”
missed or late visits
1 finding
moderate“The provider had no system to monitor calls. They were reliant on people or relative's telling them there had been missed or late calls.”
incident learning
1 finding
critical“The registered manager was not up to date with their responsibilities under the duty of candour. In addition, they were not aware of the requirement to notify CQC of various incidents.”
consent capacity
1 finding
minor“Where people lacked capacity, their representatives were involved in making decisions in the person's best interest. However, these decisions needed recording in people's care records.”
supervision appraisal
1 finding
minor“Annual appraisals to discuss training needs and work performance were not routinely taking place. However, the office manager had devised a format to enable these to take place more regularly.”
communication with families
1 finding
minor“Staff meetings were not held regularly and staff told us communication and sharing of information could be improved.”
care planning
1 finding
minor“We looked at six care and support plans in detail and found the care files did not always reflect people's needs and preferences.”