critical“audits of the quality of the service remained insufficient to alert the provider of care planning and risk assessment inconsistencies”
critical“Audits and checks completed in May, June and July 2022 had not picked up on some of the issues identified in this inspection. For example, the medicines audits had not identified the issues with medicines.”
critical“The provider had failed to give us information when asked about care packages and then provided inaccurate information about care packages.”
critical“The systems in place to audit the quality of the service were not robust or sufficient to alert the provider of concerns and issues within the service.”
care planning
3 findings
critical
“a person's care plan did not make any mention of how they transferred out of bed or the equipment required to do this safely. There was no risk assessment or guidance for staff”
critical“Risk assessments contained unclear guidance for staff...There was no guidance or risk assessment in place to detail safe ways of working with them to minimise anxiety and protect staff.”
critical“the care plans were not clear or robust and did not clearly detail what people's assessed needs were.”
record keeping
3 findings
moderate“catheter care records did not always detail when weekly use catheter bags had been replaced. Records of repositioning people...did not detail if people had been positioned on their left side, right side or their back”
moderate“Records in the service were of poor quality, were inconsistent and did not include a complete and accurate and contemporaneous record of care provided. The staff list the provider gave CQC was not complete.”
critical“Records in the service were poor. The staff list the provider gave CQC was not complete.”
staff competency
3 findings
moderate“this did not amount to a competency check to ensure specific training was embedded safely into working practice, for example, when using a lifting hoist”
critical“The provider had not explored each staff members' full employment history. The provider could not be assured that all staff were suitable for their roles.”
critical“Some staff employed to work in the community had not received any induction and had not shadowed experienced care staff”
medication management
3 findings
critical“Staff had been administering medicines to people without training and without being assessed as competent to do so. Training records evidenced that no staff had received any medicines administration training.”
critical“One person was prescribed a medicine which needed to be administered 20 minutes before meals. We observed staff administer the medicines 13 minutes after the person had eaten their meal.”
critical“One person had been prescribed antibiotics; they had missed two doses of the medicine. Medicine administration records (MAR) showed other gaps in records.”
missed or late visits
3 findings
critical“Several relatives reported that their loved ones had experienced delays in receiving support...people were having 16 hours between care visits.”
critical“One person's daily care records for 30 July 2022 evidenced that their morning care visit was carried out in 10 minutes...The person had been assessed as requiring 45 minutes for care in the morning.”
critical“It's not unusual for them to come three times a day or twice a day when it should be four times”
staff training
3 findings
critical“Only two staff had completed learning disability and autism training. The staffing rota showed that four staff regularly worked with a person who had a learning disability.”
critical“One new member of staff employed since the last inspection had not received any induction and had not done any training prior to participating in care visits with people.”
critical“The only training we receive is a link to a video to watch through WhatsApp, no actual training, no assessment.”
infection control
3 findings
moderate“We observed staff not wearing masks on the first day of our inspection. Staff working in the community reported that they are not always wearing masks...not wearing aprons when providing personal care.”
moderate“Staff had not completed food hygiene training and had not followed correct procedures for preparing and storing food...At this inspection, this had not changed.”
critical“Some areas of the service were dirty and had not been cleaned effectively. Cleaning schedules were not completed”
consent capacity
2 findings
minor“where people had a lasting power of attorney appointed for health and welfare decisions, the provider had not always retained a copy of the order”
critical“There was no record that a capacity assessment or best interest discussion had taken place.”
staffing levels
2 findings
critical“A staff member told us, 'It is impossible with the real rotas to fit in all the care calls...There are 17 hours of care visits which they fit in to a 12 hour shift.'”
critical“The provider had not ensured that sufficient numbers of suitable, experienced staff were deployed to meet people's assessed needs.”
safeguarding
1 finding
critical“The provider did not have effective systems to protect people from the risk of abuse. Staff had not received safeguarding training”
complaints handling
1 finding
critical“These complaints had not been recorded and had not been dealt with appropriately, the issues and concerns were still occurring when we inspected.”
incident learning
1 finding
critical“Incidents relating to people had not been managed safely to reduce the risk of harm.”
leadership
1 finding
critical“The provider lacked oversight of the supported living service and the domiciliary care service.”
person centred care
1 finding
critical“The provider had failed to provide care and treatment to meet people's assessed needs.”
other
1 finding
critical“A robust approach to recruitment was not taken to ensure only suitable staff were employed to provide care.”