critical“The lack of effective oversight and governance was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
critical“The provider did not have a robust system to review the quality of the service...only had time to conduct a quality check of one person's daily notes.”
critical“The provider did not have robust or effective processes in place for monitoring and improving the quality of the care people received.”
moderate“There was still no formal programme in place to ensure these checks would take place as planned.”
moderate“We noted there was no overall plan to ensure that actions and resources were coordinated effectively.”
minor
“in some instances checks were not always planned ahead to make sure they would be completed systematically.”
record keeping
5 findings
moderate“Care staff did not record the times they attended or left calls so the manager was unable to identify if people were receiving their calls on time.”
moderate“Information required to ensure people received care which kept them safe was not always carried forward when assessments were updated.”
moderate“Records were not maintained when people needed support to receive the appropriate nutrition to keep them well.”
moderate“Checks had not always been effective and had failed to identify when care staff regularly left calls early or records were not completed fully.”
minor“staff had not always accurately recorded the time they attended calls in people's records”
staff training
4 findings
moderate“There were no robust training processes to ensure staff regularly refreshed their knowledge.”
critical“The provider did not ensure that staff received an induction or training to address gaps identified in their skills and knowledge.”
critical“There was no formal induction process for new members of staff when they started working at the service.”
minor“Staff had not had refresher training in some aspects of people's specific conditions for several years.”
leadership
4 findings
critical“There had been no registered manager in place since September 2014.”
critical“The provider had not made arrangements to ensure the service had a registered manager.”
critical“There had been no registered manager in place since September 2014. Since that time one of the company directors had been managing the service.”
moderate“they had not shared details of our warning notice with the new manager to ensure their actions to improve the service addressed the concerns identified”
care planning
4 findings
moderate“This information was not recorded in people's care plans for other members of staff.”
moderate“No changes had been made to their care plan to reflect that the person was less able to be involved in their personal care.”
moderate“Most care records sampled were incomplete and did not contain information about people's lives and experiences.”
minor“Although there was guidance for how staff were to meet people's specific needs, there was no general information about the conditions people had or how they could impact upon them.”
supervision appraisal
4 findings
minor“There were no processes in place however to ensure staff would meet regularly with the manager or record the outcomes of these meetings.”
moderate“The manager told us that they had only conducted a supervision meeting with one member of staff since our last inspection.”
moderate“there was no formal programme to hold meetings or individual supervisions with staff, in order to identify how they could best improve the care people received.”
minor“Although staff received formal supervisions there were no formal plans to ensure these would be conducted consistently.”
medication management
4 findings
critical“Records did not contain clear information to enable staff to ensure medicines were administered safely.”
critical“there was no information for staff about people's medications or any risks they presented.”
minor“Details of people's creams were now in their care records but had not been included in specific medication records for staff. This did not make them easy to find and refer to.”
minor“further information was required to support people to apply creams they might require. This was being addressed.”
staff competency
3 findings
critical“Recruitment procedures did not establish or were operated effectively to ensure that people employed were of good character, have the qualifications, competence, skills and experience necessary.”
moderate“The provider had failed to ensure that staff had access to all the guidance and information they needed to ensure people were kept safe from the risk of harm.”
critical“The manager had not always checked if new staff had a criminal background before they were employed. This was in breach of Regulation 19.”
incident learning
3 findings
moderate“Although the manager had taken action when a person raised a specific concern we noted that the person had raised the same concern on several occasions before action was taken.”
moderate“The provider did not have a system to record concerns or learn from untoward incidences.”
moderate“There was no system to review serious incidents when people were put at the risk of harm in order to protect other people from similar risks.”
safeguarding
2 findings
critical“Two other staff we spoke with were not clear about who they could report safeguarding concerns to outside of the provider's organisation.”
critical“the manager was not aware of their requirement to notify the local safeguarding authority when they thought people were at risk of harm.”
consent capacity
2 findings
critical“The manager was unable to explain the principles of the Mental Capacity Act 2005 or clarify the provider's policy for assessing if a person lacked capacity.”
critical“The provider had not conducted assessments when people were thought to lack mental capacity. This was in breach of Regulation 11.”
complaints handling
1 finding
minor“Several people told us that the manager did not always respond promptly to concerns raised.”
person centred care
1 finding
moderate“Two people we spoke with told us their care plans had not been updated to reflect their changing needs.”