critical“One person was receiving medical support from staff that had not been trained to administer this medical support. This put the person at risk of harm.”
safeguarding
1 finding
critical“The provider had not reported issues of safety to the Care Quality Commission or to their local council. Incidents not reported included a staff member being threatened with violence.”
governance
1 finding
critical“Reporting systems were not in place to ensure all notifiable incidents were reported to the CQC... medicine errors had not been reported appropriately.”
care planning
1 finding
moderate“Peoples care plans did not contain enough detail to ensure they were supported in line with their needs and wishes.”
incident learning
1 finding
critical“The provider did not review incidents and accidents to look at lessons learnt. This meant that people were at risk of the same issues happening again.”
staff training
1 finding
moderate“Staff told us that if they were recruited with training in health and social care, they did not have any further training from the provider.”
staff competency
1 finding
moderate“The provider could not demonstrate that they had assured themselves that the current training their employees had was adequate and that they were competent.”
record keeping
1 finding
critical“There were gaps in the medicine administration record (MAR) that could not be accounted for and had not been identified by the registered manager.”
missed or late visits
1 finding
moderate“The registered manager had been made aware by people that there were experiencing several missed appointments which there were no prior warning about.”
person centred care
1 finding
moderate“One person told us that a member of staff had fallen asleep whilst working with a relative. Another person told us 'There wasn't a massive amount of engagement' from staff.”
supervision appraisal
1 finding
moderate“The registered manager told us they had not received regular supervision. This meant the provider had no oversight of their working practices.”
leadership
1 finding
critical“During the inspection both the registered manager and the assistant manager left their posts.”
communication with families
1 finding
minor“People told us that at times communication was difficult with their carers, as English was not always their first language.”