moderate“Most people and their relatives said communication from the service was poor and although some relatives said this has improved slightly, more improvement was needed.”
moderate“Some relatives had not been told about visiting restrictions being lifted following an outbreak of COVID-19 in the service. One relative told us they hadn't been informed when their loved one had been taken to hospital.”
moderate“People and their relatives consistently told us that communication was a problem.”
complaints handling
2 findings
moderate“Relatives told us that some minor concerns they reported were not always addressed quickly... most relatvies reported things going missing... they had not taken any action and there had been no improvement.”
minor
“There was no separate log of complaints which made it difficult for the manager to see the investigation, actions taken”
governance
2 findings
minor“These changes were still new when we inspected and needed more time to become embedded in the service.”
critical“Peoples' care plans and risk assessments were not always up to date. The provider did not have robust mechanisms in place to monitor the safety and quality of the service.”
medication management
2 findings
minor“At the last inspection we saw fridge temperatures were not always recorded. At this inspection this had improved but was still not consistent.”
minor“where medicines are required to be stored in temperature-controlled conditions, the temperatures were not consistently recorded”
leadership
1 finding
moderate“The service did not have a manager registered with the Care Quality Commission (CQC) and the CQC had not received an application at the time of this inspection”
person centred care
1 finding
critical“The provider failed to ensure that peoples' care was personalised to meet their individual needs”
care planning
1 finding
moderate“not all risk assessments and care plans were up to date and there were no systems in place to ensure reviews took place”
staffing levels
1 finding
moderate“There weren't always enough staff deployed to meet peoples' needs”
staff competency
1 finding
moderate“Staff didn't always know people very well, and they were not always able to tell us about the people they were supporting”
incident learning
1 finding
moderate“There was no mechanism in place for sharing lessons learned across the staff team or the wider organisation.”
record keeping
1 finding
moderate“Daily records of care were lacking in detail and mainly consisted of standard phrases from a tick list”
staff training
1 finding
moderate“healthcare professionals who worked with the service had identified concerns about staff knowledge in topics such as feeding tubes, wound care, nutrition, fluid intake and dementia”
infection control
1 finding
minor“Effective nursing measures were not in place for a person who was showing signs of an infection.”
safeguarding
1 finding
moderate“emergency services had been called for a person showing signs of dehydration, which were reported to the local safeguarding authority”