critical“Records to evidence how medicines were administered to people to ensure they were administered as prescribed were not provided or available when requested.”
care planning
1 finding
critical“The provider had moved to a new electronic system in January 2022 but did not have up to date care plans for people they supported.”
missed or late visits
1 finding
moderate“Occasionally we've not had anyone turn up until it's too late, and I've had to do it myself, so I've cancelled and rung the company to tell them.”
staffing levels
1 finding
critical“The provider failed to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons were effectively deployed.”
governance
1 finding
critical“Since our last inspection in September 2018, the provider had failed to carry out regular audits to identify issues.”
safeguarding
1 finding
critical“CQC and safeguarding team had not been notified of two possible allegations of abuse. Systems in place to ensure provider oversight had failed to identify this.”
incident learning
1 finding
moderate“There was no analysis of trends to identify areas of learning to be shared with staff, so there could be a positive impact in improving people's experience.”
complaints handling
1 finding
moderate“Not all complaints made, were logged and investigated in line with the provider's complaints procedure.”
person centred care
1 finding
moderate“Care records did not contain background information about people so care staff could know more about the person they were supporting.”
record keeping
1 finding
moderate“Detailed information about accidents and incidents was not recorded and the provider failed to carry out any analysis.”
end of life care
1 finding
minor“Care records did not contain advance decisions about people's choices about the end of their life. The registered manager told us that they had not explored this.”
communication with families
1 finding
moderate“Relatives we spoke with told us that communication with the management team was poor and this needed improvement.”
cultural competency
1 finding
minor“Care records failed to guide staff about people's cultural requirements in relation to their diet; to ensure they were supported according to their needs.”
infection control
1 finding
minor“Some people and relatives told us that staff sometimes wore PPE and at other times did not, or not at all, while other people and their relatives said that staff always wore PPE.”
leadership
1 finding
critical“The registered manager did not have a good understanding of their role, regulatory requirements and lacked oversight of the service.”