critical“The provider could not demonstrate that there were formal systems in place to monitor the quality of care provided.”
critical“There was no system in place for the provider to be sure that people received their visits from staff. The only way the provider would know if a visit had been missed was if a person called.”
critical“The provider could not demonstrate that there were formal systems in place to monitor the quality of care provided.”
critical“We inspected again in January 2017 and found there was still no thorough system of monitoring the effectiveness of the service.”
moderate“We need to ensure that the improvements made are embedded into the service and that they are sustainable.”
record keeping
2 findings
moderate“The last recorded training date displayed was 23 July 2015...Another depicted a care plan review schedule. No current review dates were listed. The last recorded date was 2 July 2015.”
critical“For one person we found no records of visits and communication sheets since 18 May 2014, fluid chart records since 12 January 2014.”
incident learning
2 findings
moderate“There was no system in place to monitor and analyse accidents or incidents to look for patterns or trends.”
moderate“The provider could not demonstrate how concerns and complaints reported were used as an opportunity for learning and development.”
leadership
1 finding
critical“There was not a registered manager in post. The service was also operating from a location that was not part of the conditions of their registration.”
care planning
1 finding
moderate“One risk assessment stated the person could not bear weight and needed a hoist for all transfers...but there was no detailed guidance for staff relating to the risk or how to hoist the person safely.”
supervision appraisal
1 finding
critical“Staff had not received regular formal supervision and appraisals to monitor their performance and development needs.”
staff training
1 finding
moderate“Not all staff we spoke with had received training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).”
person centred care
1 finding
moderate“We could not find evidence in people's care plans about people's personal histories, likes and dislikes.”