moderate“There was documentation to record people's capacity within the care files, but this was not always completed as required.”
moderate“Some of these were signed by the person and others by their representative. It was not always clear why a representative had signed.”
moderate“the provider had not provided staff with training in this area and records for mental capacity had not been consistently completed across the service”
missed or late visits
2 findings
minor“They sometimes turn up late, but they always get here. Timings have been erratic, but we didn't know about the half hour bandings, we now understand.”
critical
“Another safeguarding concern had been raised in relation to missed visits which had resulted in harm.”
communication with families
2 findings
minor“Sometimes staff are difficult to understand. Sometimes they speak loudly and it sounds like shouting.”
minor“I just wish the office would ring if they are caught up in emergencies or delayed to let me know they are running late”
safeguarding
2 findings
critical“One person had been assessed as needing two carers to support them with all transfers but told us, that until recently, transfers had regularly been performed by one carer.”
moderate“six care staff had not received safeguarding awareness training”
governance
2 findings
critical“The provider had failed to maintain good governance. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
critical“The provider had failed to maintain good governance. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations, 2014.”
care planning
2 findings
minor“The registered manager had not always recorded these phone calls in the person's daily records but had begun a log of calls in the office.”
moderate“systems and processes for assessing the quality of the service were not robust to ensure audits were taken for the quality of the care records, staff recruitment files and staff training needs”
record keeping
2 findings
minor“We did not see any records in the daily records of any referrals. Staff told us they informed the manager who would make the necessary referral.”
moderate“quality of care records and the recording was not consistent and robust especially in respect of ensuring details about consent to care and risk assessments had been clearly documented”
incident learning
1 finding
moderate“There had been a long delay in notifying CQC of this incident... a notification had not been submitted as soon as the registered manager had been aware of an incident.”
complaints handling
1 finding
minor“Not everyone we spoke with felt confident their complaint or concern had been listened to, one person told us they had to raise a matter a few times before it was addressed.”
staff training
1 finding
critical“not all care staff who had been employed at the service had completed training in a number of areas...challenging behaviours, emergency awareness, dementia awareness, mental capacity, equality and diversity”
supervision appraisal
1 finding
minor“not all supervision records had been signed by the registered manager and staff”