critical“Systems were not yet robust enough to demonstrate good governance. This was a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008.”
critical“Governance and monitoring systems were ineffective and failed to ensure people were safe, their rights were protected and they received quality care and support.”
care planning
2 findings
critical“At the time of our inspection not all care plans and risk assessments for people had been reviewed. This meant people were at risk because staff did not always have the guidance they needed.”
moderate“People's care and support plans did not promote strategies to enhance independence and demonstrate evidence of planning and consideration of their longer-term aspirations.”
record keeping
2 findings
moderate“Auditing of staff files had begun, and gaps had been identified in some records. However, where actions were required, it was not always evident how this was effectively tracked and managed.”
moderate“One person's care plan contained another person's name and other care records contained generic information not relevant to the person whose care plan it was.”
communication with families
2 findings
moderate“People and relatives shared that the handover process when the live in carers changed over was not always a smooth transition and communication was still mixed at times from the office.”
minor“Several people and relatives shared examples of poor communication and an unsettling and disruptive service during the changeover period.”
consent capacity
2 findings
moderate“Work was ongoing to ensure the Mental Capacity Act was fully understood at all levels within the service and that records and practice supported shared decision making.”
moderate“People were presumed to not have capacity and a blanket MCA form was used for assessment. An MCA policy and procedure to guide and inform on safe practice was not in place.”
incident learning
2 findings
minor“Reporting and auditing systems had been introduced but it was too soon to assess their overall effectiveness.”
moderate“There was not an effective system to monitor and analyse accidents and incidents for patterns and trends in place.”
safeguarding
2 findings
critical“CQC were not informed of three safeguarding concerns. This is important for oversight of safety.”
critical“The provider did not have oversight of recruitment processes to ensure fit and proper persons were employed. This failure placed vulnerable people at risk.”
medication management
2 findings
moderate“We found unexplained gaps in the Medicine Administration Record (MAR) chart for one person which had not been identified or followed up to ensure medicines were received as prescribed.”
moderate“Protocols for medicine to be administered 'as required' were not in place to guide staff.”
person centred care
1 finding
moderate“Care and support was not always person-centred and did not promote people's dignity, privacy and human rights.”