critical“Medications were not always recorded on a Medication Administration Record (MAR). Some MARs we viewed had missing signatures which would indicate medication had not been administered as prescribed.”
minor“We could not improve the rating for safe to good because to do so requires consistent good practice over time.”
critical“Medicines were not managed and administered safely which placed people at significant risk of harm.”
care planning
3 findings
critical“Care plan documentation contained information which was either inaccurate or insufficient to enable staff to support people effectively. For example, one person's care record stated they required support with catheter care. The person did not have a catheter.”
moderate
“some of the information had not been recorded consistently in all areas of the electronic system which meant staff may not have always been up to date with people's needs”
critical“Care plans were not audited or reviewed... Some care plans were out of date and had not been reviewed but the provider had not identified this.”
governance
3 findings
critical“The care notes and MAR audits we reviewed were not completed on a regular basis. Only one of these eight records had been completed since our last inspection in the month of July in 2021.”
moderate“the service management and leadership needed to remain consistent over time. Leaders and the culture they created had begun to support the delivery of high-quality, person-centred care.”
critical“The provider failed to operate an effective governance system to assess, monitor and improve the quality and safety of services provided.”
record keeping
3 findings
moderate“The provider had no effective way of ensuring staff had received training and supervision. Training and development records were not held centrally.”
moderate“Care plans had been transferred to the electronic care planning system... However, some of the information had not been recorded consistently in all areas of the electronic system”
critical“MARs were handwritten and incomplete. They did not contain all the information required to administer medicines safely including the medicines full name, dosage and frequencies.”
safeguarding
2 findings
critical“An incident we were made aware of during the inspection had not been referred to the relevant safeguarding authority, which meant there had not been an investigation carried out to protect the person.”
critical“We found there were 10 allegations of abuse that had been recorded in a safeguarding folder at the service. The service had not notified CQC.”
consent capacity
2 findings
critical“The provider did not have up to date mental capacity assessments in place where people lacked the capacity to make all of their own decisions.”
moderate“We found some examples of relatives giving consent on behalf of a person, without the legal authority to do so.”
staff training
2 findings
critical“We could not be assured staff had received mandatory training such as moving and handling as records did not reflect this. Evidence of these training certificates were out of date.”
critical“The only training I have done with Falcon was medication, I didn't have any moving and handling training with them. I did support people who needed hoisting.”
staff competency
2 findings
moderate“Some staff had received competency checks, but the provider could not evidence all staff had received checks to ensure staff were skilled and proficient in their role.”
critical“Staff were not competent and skilled enough to provide safe and effective care to people.”
supervision appraisal
2 findings
moderate“The provider was unable to provide evidence to show staff received regular supervisions to monitor staff performance and development.”
moderate“Staff did not receive regular supervision. The provider told us that most supervisions took place informally and were not documented.”
incident learning
2 findings
critical“The provider had not implemented sufficient systems and processes to learn lessons when things went wrong. The last inspection rated the service inadequate and we found little or no improvements had been made.”
critical“We found there were no accident or incident forms completed regarding these injuries and no action had been taken to reduce the risks to the person or reduce the risk of reoccurrence.”
leadership
2 findings
critical“The provider lacked effective oversight of the service and the systems and processes in place. The provider was unable to readily access documentation held electronically.”
critical“The provider, who was also the manager, had little oversight of the service. They did not have prompt access to all records and documentation required.”
missed or late visits
2 findings
moderate“Staff are sometimes very late for calls, but staff will phone and tell us they will get to us as soon as they can.”
moderate“The evening call should be 9pm but it can be 8:30pm or 9:45pm, it's impossible to settle when you don't know, it doesn't aid recovery.”
complaints handling
2 findings
minor“The provider was producing a new log for complaints which would include response dates to bring it in line with the policy.”
critical“There was no effective or accessible system for managing complaints. Complaints were not always appropriately recorded and investigated.”
person centred care
1 finding
critical“The care that people received did not always meet their needs or reflect their preferences.”
communication with families
1 finding
moderate“I find communication at this (management) level not the best... Then the next part of the email was a copy and paste job from a generic COVID-19 email.”
cultural competency
1 finding
moderate“If [staff] knew what you were talking about, they might respect your culture. I'm Irish catholic and was married to a Punjabi but they don't have a clue.”
other
1 finding
critical“Recruitment procedures were not established and operated effectively to ensure that staff were suitable to work with people who used the service.”