minor“the records we saw for the one to one supervision meetings were brief and the registered manager agreed they needed to be expanded in order to maintain an accurate record”
minor“The registered manager also acknowledged the majority of care workers had not had an appraisal in the previous year, as there had been a high turnover of staff.”
care planning
2 findings
critical“All the care plans and risk assessments we looked at had a default review date of May 2015 and there was nothing to indicate the reviews had been completed.”
critical“care plans had not been updated and might not have reflected people's needs at the time. Care plans we looked at had a default review date and there was nothing to indicate the reviews had been completed”
complaints handling
2 findings
moderate“The policy was not routinely given to people or their representatives as part of the information given to them about the service.”
moderate“The provider's complaints policy was not readily available or routinely given to people who used the service.”
governance
2 findings
critical“The registered manager had not informed the CQC of a significant incident where there were allegations that a person had been abused.”
critical“The provider did not notify the Care Quality Commission (CQC) of significant incidents which they are required to do under legislation.”
medication management
1 finding
critical“Some care workers initialled the MAR with their first name only and others ticked the record. We also noted there were a number of gaps on the MAR where it could not be established from the record if medicines had been given.”
person centred care
1 finding
moderate“During August and October 2015 we found examples where a person who required a single care worker per visit, had eight different workers in a seven day period.”
staffing levels
1 finding
moderate“The registered manager, who told us they had continuous difficultly recruiting and retaining staff.”
record keeping
1 finding
moderate“The provider had also not carried out recent checks to make sure the medicines records were completed as required to confirm that people received their medicines as prescribed.”
incident learning
1 finding
critical“people were not protected from the risks of poor care as the registered manager had not informed CQC of significant incidents that had occurred.”