moderate“The management team did not always communicate effectively with staff and health and social care professionals or create a culture that empowered staff.”
moderate“Effective systems were not fully in place to monitor the quality of the service being delivered and staff development.”
critical“There had been a failure to establish and maintain effective quality assurance systems within the service.”
leadership
2 findings
moderate“The majority of staff did not feel supported or valued by the management team. Of the 11 staff that provided feedback to us, 9 raised concerns about support from the management.”
critical
“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
record keeping
2 findings
moderate“A medicines audit had been developed... However, these audits had not been recorded. The registered manager told us they were auditing care plans, but these had also not been recorded.”
critical“Medication administration records (MAR) had not always been maintained, to the extent it was not possible to be assured people had received their medicines as prescribed.”
care planning
2 findings
moderate“the associated care plan had not always been updated to reflect people's current level of need... For another person, their care plan still reflected their old care schedule which had changed due to a change in their needs.”
critical“Risk assessments were not always in place for people. Some people had no risk assessments or management plans in relation to moving and handling, skin care or continence care.”
medication management
2 findings
minor“they had recognised that not everyone's medicines care plans contained clear guidance around the support people required with their medicines.”
critical“We were not assured that people had received their medicines as prescribed and in line with the provider's policy and national guidance.”
communication with families
1 finding
moderate“2 professionals raised concerns that communication from the management team had been poor at times, which had led to an inconsistent service and a delay in an assessment.”
infection control
1 finding
critical“We could not be assured that all staff took part in weekly COVID-19 testing... the registered manager did not have a process to check staff compliance with testing.”
staff training
1 finding
critical“Three of the staff records we looked at contained no evidence of staff training. Another staff member had completed training, but this had all expired over 12 months ago.”
supervision appraisal
1 finding
moderate“We discussed staff supervision with the registered manager who told us formal staff supervision was not taking place.”
missed or late visits
1 finding
moderate“People and their relatives told us staff punctuality was inconsistent and staff would not always arrive on time. People and relatives told us they felt rushed by staff.”
staff competency
1 finding
critical“The service had not always carried out the relevant checks in relation to people's employment history, qualifications, or conduct in previous roles... had not always carried out DBS checks on all staff.”
incident learning
1 finding
critical“There had been seven notifiable incidents since the beginning of June 2020. The registered manager had failed to notify CQC of these incidents.”
consent capacity
1 finding
moderate“We also saw that people's consent to care had not always been recorded in people's care files.”
person centred care
1 finding
moderate“concerns found at the inspection included but were not limited to, training, care records, risk management, consent and the mental capacity act and lack of person-centred information.”