minor“Records did not always show the referrals made and any advice from the health care professionals. This was raised with the registered manager.”
moderate“Care plans did not always contain detailed information individual to the people using the service, to ensure that their needs were met.”
governance
1 finding
critical“The provider did not have suitable systems and processes in place to assess, monitor and improve the quality of the service... breach of Regulation 17”
safeguarding
1 finding
critical“a staff record indicated a person using the service could have been abused. This had not been reported to the safeguarding authority or to CQC as legally required.”
care planning
1 finding
moderate“there was no risk assessment in place for a person recorded as having diabetes. There was also no risk assessment in place for a person who had moving and handling needs.”
staff training
1 finding
moderate“staff had not received training on people's specific health conditions such as training on strokes, diabetes and sensory impairment.”
supervision appraisal
1 finding
moderate“One staff member who had been in post nearly six months had not yet had supervision. Records of staff appraisal were limited to the staff member's assessments of their own performance”
staff competency
1 finding
moderate“Training questionnaires, designed to test whether staff had sufficient knowledge of the subject after completing training, had not been assessed by management to test staff competencies.”
incident learning
1 finding
moderate“There was no information in place to indicate that any lessons had been learnt from this situation to prevent it from happening again.”
missed or late visits
1 finding
minor“People and relatives told us that they received a timely service although records showed that some calls had been early or late.”
complaints handling
1 finding
minor“The procedure also implied that complainants could contact CQC if they were not satisfied, to have their complaint investigated. CQC does not have the legal power to investigate complaints.”
other
1 finding
moderate“the provider had failed to obtain a reference from relevant previous employment in care, as they had not checked the employment history for a member of staff.”