critical“Systems had not been established to assess, monitor and improve the safety and quality of the service. This was a continued breach of regulation 17(1)”
critical“There were no effective quality assurance systems in place. Some medicines audits had been completed, however, these were incomplete or undated or unsigned.”
moderate“The provider was not completing any of their own audits...audit information was limited.”
critical“As there were no robust auditing systems in place the provider was not identifying and rectifying short falls in the service.”
record keeping
3 findings
moderate
“We were assured some checks were in place of care records but they were informal and required more detail.”
critical“There were no accident or incident reports. However, daily records showed accidents and incidents had occurred.”
critical“Medicine records had not always been completed correctly to show medicines had been given or a reason entered if they had not been given.”
medication management
3 findings
critical“Medicine administration records (MARs) indicated medicines had not been given on numerous occasions, with no reasons recorded for the omissions.”
critical“Some medicines had been given more frequently than prescribed and some medicines had been given less frequently than prescribed.”
critical“Care staff confirmed no medicines care plans were in place to inform staff what medicines were for or guidance about when any 'as required' medicines may need to be given.”
incident learning
2 findings
minor“The registered manager maintained a log of any falls but there was no system to maintain an overview of accidents and incidents.”
critical“Significant shortfalls were identified at this inspection with similar concerns to those found at our previous inspection. These issues had not been identified or addressed.”
missed or late visits
2 findings
critical“[Staff] don't often stay the full time. About 10 minutes instead of 30 minutes. That is regular”
minor“People we spoke with told us care workers did not always arrive at the time they expected.”
care planning
2 findings
critical“Care records were not accurate, did not reflect people's needs and were not clear about what care was to be provided on each call.”
minor“Care workers knew people well and how they liked their care and support to be delivered. This level of detail had not always been recorded in their care plan.”
leadership
2 findings
critical“The registered manager resigned with immediate effect the day before the inspection. The registered manager had not been in the service on a full-time basis.”
moderate“There was no registered manager in post. A manager had been recruited and was in the early stages of registering with the Care Quality Commission.”
complaints handling
2 findings
moderate“People and their relatives told us they had raised complaints and said these had been dealt with. However, the provider confirmed there were no complaint records.”
moderate“Concerns people were raising were not being routinely logged or responded to.”
staff competency
1 finding
critical“Robust recruitment checks were not in place. We found gaps in staff employment histories had not been explored and dates on references were not always consistent”
safeguarding
1 finding
critical“The provider failed to identify, investigate and report safeguarding concerns to CQC or the local authority. The deputy manager confirmed there were no safeguarding records.”
staffing levels
1 finding
critical“Staff were not effectively deployed to meet people's needs. Regulation 18 (1)”
end of life care
1 finding
moderate“There were no end of life care plans in place or any evidence of people's preferences and choices in relation to end of life care had been explored with them.”
consent capacity
1 finding
moderate“The registered manager and quality manager were unsure if any relatives or representatives had Lasting Power of Attorney (LPA) for property and finance or health and welfare.”