moderate“Some care files lacked detailed guidance for staff on how to support people with specific care needs.”
moderate“Two people told us they did not know they had a care plan. One person commented due to a disability, they would need help to read the care plan, but this help had not been offered.”
minor“We found for one person their care plan had not been updated to reflect their current needs. The registered manager agreed to address this.”
minor“They provided some detail but did not give instructions for frequency of interventions and what staff needed to do to deliver the care in the way the person wanted.”
moderate“A behavioural care plan was not in place to provide guidance for staff to follow when the person became distressed.”
governance
4 findings
critical“Systems to ensure the quality of performance and compliance with regulatory requirements had not consistently enabled the registered manager and provider to identify failings.”
critical“Systems to ensure the quality of performance and compliance with regulatory requirements had not consistently enabled the registered manager and provider to identify failings.”
minor“audits of medication records were completed only a sample of these were reviewed each month...a couple of gaps had not been explored and the rationale provided”
minor“Discussion took place with the registered manager to ensure effective monitoring and audits captured people's comments about any lateness of calls or changes in workers'.”
safeguarding
3 findings
critical“1 incident which had not been recognised as requiring a safeguarding alert to the local authority safeguarding team.”
critical“Some incidents which required investigation to determine whether abuse had occurred had not been shared with the local authority safeguarding team.”
critical“A risk assessment had failed to identify the inappropriate use of restrictive intervention for 1 person...left the person at risk of avoidable harm.”
record keeping
3 findings
moderate“Guidance on catheter care was not always sufficiently detailed and the positioning of a person during percutaneous endoscopic gastronomy (PEG) feeds was not addressed.”
moderate“1 person's file lacked guidance for staff on how to support a person's mobility needs. Another file lacked guidance on percutaneous endoscopic gastrostomy (PEG) care.”
minor“physical evidence of their full employment with gaps explored and explained was not initially available for three of the four staff files we reviewed”
incident learning
2 findings
moderate“Systems in place to address, investigate and learn from when things go wrong were much improved. However, they had not identified an incident which needed to be shared with the local authority safeguarding team.”
moderate“Incidents were not always recorded and analysed effectively...Opportunities to learn were missed because the information gathered to feed into the systems was insufficient.”
communication with families
1 finding
moderate“Two people told us they had had difficulty in communicating with staff. One person told us they felt 1 carer was not able to speak English at all.”
end of life care
1 finding
moderate“A care plan for a person receiving end of life care was very basic and did not contain much detail about the person's needs and wishes.”
medication management
1 finding
minor“Systems had failed to enable staff to seek medical advice about a possible missed medication in a timely way.”
complaints handling
1 finding
critical“Systems to investigate and act upon complaints were not robust. This meant complaints were not always fully investigated and people did not always receive clear outcomes.”
cultural competency
1 finding
minor“Some people's care records contained limited information about how the needs defined by their equality characteristics could be met...limited or no information about people's religious or spiritual needs.”
leadership
1 finding
critical“The registered manager and provider had failed in their legal duty to notify CQC of some notifiable incidents.”
consent capacity
1 finding
minor“Documentation about people's ability to make decisions for themselves was not always very clear.”
infection control
1 finding
minor“Some people told us carers had been running out of gloves. One person told us they had been giving carers gloves from their own supply.”
staffing levels
1 finding
moderate“We don't always get two staff at the calls when [Name] has been assessed as needing two support workers four times a day.”
person centred care
1 finding
minor“[Name] has the same care workers 40% of the time. Don't always get to know if someone different coming”