moderate“Not all audits had been fully completed but we were assured the new framework was being followed to monitor and review the quality of the service.”
minor“Accidents and incidents were to be analysed for trends and themes but at the time of inspection this aspect of the governance framework had not been fully completed.”
critical“Audits were not all effective as they had not identified issues found at inspection. Robust systems were not in place to monitor the quality of care provided.”
moderate“At the time of the inspection we could not assess the effectiveness of these audits in driving sustainable improvements due to the short period of time that they had been implemented.”
critical“37 care plan audits were overdue, one since January 2015. The registered manager did not always understand their responsibilities to make notifications to the CQC.”
care planning
3 findings
critical“Care plans did not give instructions for frequency of interventions and what staff needed to do to deliver care in the way the person wanted.”
moderate“Care plans were not always person focused and personalised to ensure that people received care that was responsive to their needs. They did not always contain the preferences of people.”
critical“Three care plans we looked at showed that people received support from the service before their needs were assessed... staff were caring for the person with no care plan or assessment to follow for at least one week.”
record keeping
3 findings
critical“Records did not always reflect the care provided by staff to ensure people received care and support in the way they wanted and needed.”
moderate“Another person's MAR had some blank spaces where nothing had been recorded... There was no coding in place to explain this.”
critical“Care plans recorded whether a person was taking medicines but did not document what those medicines were.”
incident learning
2 findings
moderate“We found two incidents which had not been notified to the CQC which related to injuries. The registered manager and nominated individual were unware that this type of incident had to be notified.”
moderate“Safeguarding incidents were investigated and action plans were created but it was not always clear that remedial action had been taken.”
missed or late visits
2 findings
critical“67% of the respondents replied, 'My care workers don't arrive on time' and 47% of people responded, 'Staff don't stay the agreed length of time.'”
moderate“Three people and two relatives told us that appointments were often missed without them being given notice, or that staff attended late.”
person centred care
2 findings
moderate“Staff were not provided with the required information before they began to work with people to ensure they delivered the correct support.”
moderate“Care plans were not always written in a person-centred way. It was not always clear from care plans what level of support people needed or had requested.”
communication with families
2 findings
moderate“Staff reported if they telephoned the office to say they were running late, the person was not always contacted to inform them the care worker would be late.”
moderate“People said that when appointments were missed or staff were running late communication from the service was poor.”
medication management
2 findings
critical“Staff were not provided with the appropriate information or systems to enable them to safely administer medication within a community setting.”
critical“Some sheets contained blank entries which meant it was not possible to see whether medicines had been administered at specified times. Two people's sheets had blank entries on 17 different days over a three month period.”
safeguarding
2 findings
critical“Remedial actions were not always risk assessed and adequate controls were not always put in place to effectively protect people from the risk associated with potential abuse or neglect reoccurring.”
critical“The service did not have a safeguarding policy and investigations of incidents were not always fully recorded. Staff had not reported alleged abuse of a person.”
consent capacity
2 findings
moderate“The service did not explore the conditions attached to lasting power of attorneys to ensure that they acted in accordance with decisions made lawfully, and in the best interests of people.”
moderate“We saw no evidence of the assessment of capacity or any formal record of decisions being made in people's best interest.”
staff competency
2 findings
minor“A quality assurance officer had been recruited since the last inspection. We found that this person had no previous experience of quality assessment.”
moderate“We saw no evidence of an assessment of competency on any of these questionnaires. Staff were providing support without having relevant training or their competency assessed in specialist areas.”
staffing levels
1 finding
critical“Staffing rosters showed people's visits were back to back and travelling time was not calculated. Rosters showed some support staff were rostered to be at one house at the same time as starting a call at another.”
infection control
1 finding
critical“100% of respondents disagreed that, 'The care and support workers do all they can to prevent and control infection (for example, by using hand gloves, gel and aprons).'”
supervision appraisal
1 finding
critical“46 members of staff had received no supervision or appraisal in 2015, despite them being scheduled.”
staff training
1 finding
critical“One member of staff had not undertaken medicines training since 2006 or safeguarding training since 2009. Two members of staff had never received mandatory training.”
complaints handling
1 finding
moderate“The service had a complaints policy, but this only related to written complaints. There were no records to show that investigations of complaints occurred or remedial action taken.”
leadership
1 finding
moderate“The registered manager did not always understand their responsibilities to make notifications to the CQC. We saw that we had not been told about some relevant matters.”