moderate“People's care plans were not always personalised or detailed. This meant there was a risk people may not receive care in their preferred way.”
moderate“We found a risk assessment which had not been updated to reflect a change in a person's mobility and one which had not been updated to reflect a change in how a person was supported.”
governance
2 findings
critical“The provider has been rated as requires improvement or inadequate in the well led domain for 4 of the last 5 inspections with repeated breaches of regulation 17.”
critical“The provider's systems for monitoring the quality and safety of the service were not effective and had failed to identify the concerns we found during the inspection.”
record keeping
2 findings
moderate“Supervision and appraisal records were poorly completed and it was not always clear when staff supervisions had taken place.”
moderate“People's medicines records were not always collected regularly from people's homes and this meant the management team were not able to review them to ensure no errors had been made.”
incident learning
2 findings
moderate“There was no analysis to identify and understand any trends or themes to drive improvement. This was also identified as an issue at the last inspection.”
moderate“There were no minutes recorded for their team meetings and the supervision notes viewed lacked detail. This meant it was difficult to evidence how lessons learnt were being discussed.”
safeguarding
1 finding
critical“We found not all concerns had been raised with CQC where appropriate.”
end of life care
1 finding
moderate“We found 1 person's care plan had not been updated to reflect they were now receiving end of life care.”
complaints handling
1 finding
minor“It was not always clear what actions they had taken or how the complaint had been resolved.”
supervision appraisal
1 finding
moderate“Supervision and appraisal records were poorly completed and it was not always clear when staff supervisions had taken place.”
leadership
1 finding
moderate“You don't always get feedback when you report something. There's terrible communication and you're too scared to say anything. You're made to feel uncomfortable.”
person centred care
1 finding
moderate“The provider did not always empower people to have choice and control over the timing of their care visits.”
staffing levels
1 finding
critical“"They do not have enough staff to provide appropriate care. [Person] doesn't always get their full time, some [staff] are in and out in 10 minutes"”
missed or late visits
1 finding
critical“People had experienced missed and late care visits and this had not always been promptly identified by the provider.”
medication management
1 finding
critical“We found recording errors on one person's administration record for an important medicine, which had not been identified by the provider.”
communication with families
1 finding
moderate“"We have not been contacted for feedback or if we require any changes," and "I have never been asked for feedback."”
infection control
1 finding
minor“We received mixed feedback about whether staff were using appropriate personal protective equipment [PPE] when providing care.”