minor“The registered manager had not submitted their annual Provider Information Return (PIR) to CQC.”
critical“The provider failed to ensure robust systems and processes were in place to manage the service effectively. Systems and processes in place to assess, monitor and improve the service were not effective”
incident learning
2 findings
minor“The provider informed us they would re-introduce a monthly analysis of accidents and incidents to strengthen the systems in place.”
moderate“Regular reviews of accidents and incidents to identify any patterns or themes and identify where lessons could be learned did not take place.”
supervision appraisal
2 findings
minor“Surveys had not been completed recently by staff. The registered manager explained there was recent discussion with staff about different formats of gathering feedback.”
minor“There was no overall tracker to show when these took place, so the provider could not confirm these occurred at the frequency set out in their policy.”
staff competency
1 finding
critical“Safe recruitment processes were not always followed. For example, there were gaps in employment histories, not all employees had references and there was no up to date photograph of each staff member.”
record keeping
1 finding
moderate“Records management was disorganised and chaotic. For example, we found multiple systems in use... This made accessing the correct information difficult.”
care planning
1 finding
moderate“some people were at higher risk of pressure wounds or expressing distressed behaviour but the care plans in the office had not been updated in over twelve months.”
medication management
1 finding
moderate“Guidance for staff to follow when medicine was administered 'as needed' was not held on the electronic system... was not available during the inspection.”
staffing levels
1 finding
moderate“The staff rota we looked at included staff scheduled to work up to 18 calls in a day starting at 6.15am and finishing at 9.10pm.”
leadership
1 finding
moderate“The provider was not prepared or organised to facilitate a CQC inspection. Gaining access to the necessary information to complete the inspection was difficult.”