critical“Care plans lacked detail and were not written in a person-centred manner. The initial assessment of need did not provide information on how and what care should be provided.”
critical“People at risk of falls did not have appropriate risk assessments to help reduce the likelihood of falls.”
governance
2 findings
critical“Systems put in place to monitor the service were ineffective. Audits were last completed in March 2021 and failed to identify concerns found during this inspection.”
critical“The manager did not have any quality assurance systems in place to monitor the service.”
record keeping
2 findings
critical“Daily notes provided for 18 to 21 March 2022 were not dated and did not provide a time when care was provided.”
moderate“Records were not always available at the service and when they were, they were not always fully completed.”
consent capacity
2 findings
moderate“There was still a lack of understanding of the principles of the MCA around assessing a person's capacity and best interest decisions.”
critical“The manager had not attended mental capacity act training and required prompting when we checked their understanding.”
leadership
2 findings
critical“Provider did not have an awareness of the number of breaches from the last inspection and appeared confused when asked how they had met these since our last visit.”
critical“The manager failed to demonstrate good leadership qualities and oversight of the service.”
incident learning
2 findings
moderate“Further improvements were required to ensure learning from incidents and CQC notifications were included in the process.”
critical“We did not see any systems in place to show how the service would learn after incidents or when things went wrong.”
person centred care
2 findings
critical“Care plans lacked detail about people's preferences for care and were not written in a person-centred manner.”
moderate“People's care plans were more personalised but lacked specific details about preferences and goals people wanted to achieve.”
complaints handling
2 findings
moderate“No records were available despite a complaint made by a relative to the service in 2020. This was not in line with the provider's complaints policy and procedure.”
critical“complaints were not being recorded and investigated in accordance with the providers policy and procedure.”
infection control
1 finding
minor“We were not always assured that the provider was preventing visitors to the office from catching and spreading infections.”
staffing levels
1 finding
critical“People requiring two carers were at risk of harm as they did not receive two carers to provide support.”
staff training
1 finding
critical“The manager had not completed any recent raining relevant to their role to show they had the knowledge to provide safe and effective support to people.”
safeguarding
1 finding
moderate“The manager had a criminal records check but it did not include a vulnerable adults check.”
communication with families
1 finding
moderate“Several times I've been shouted at. Management are aggressive and unprofessional.”