critical“5 people did not have detailed care plans in place which meant it was hard to find information on how people wished their care to be delivered.”
moderate“risk assessments did not give the detailed guidance in how to mitigate risks in areas such as moving and handling and other identified risks to people's well-being.”
moderate“Care plans listed the support required but lacked the guidance for staff on how to deliver the support as the person wanted.”
governance
3 findings
critical“The provider did not have effective quality assurance systems in place to monitor, manage and improve service delivery.”
moderate
“Audits were not completed to ensure the quality of the service...the registered manager told us due to being so 'hands on' they had not completed the required audits.”
minor“call logs were not audited to ensure late calls were looked at.”
record keeping
2 findings
moderate“Accurate, complete and contemporaneous care records were not always maintained... the registered manager was not aware that staff were not recording or completing information correctly.”
moderate“staff application forms lacked the appropriate dates of previous employment required to allow the provider to check any gaps in their work history.”
medication management
1 finding
critical“Medicines were not being managed safely. In some people's risk assessments, there was no information on the types of medicines people were using, how to store it or the possible side effects.”
person centred care
1 finding
critical“There was no information recorded on people's likes and dislikes, how they liked their personal care to be delivered, oral hygiene, people's backgrounds, hobbies or interests.”
consent capacity
1 finding
critical“The provider had not completed capacity assessments for people whose capacity to consent was in doubt.”
staff training
1 finding
moderate“It was mandatory for the provider to provide training for staff in learning disability and autism. The Nominated Individual was not aware that this training was required.”
supervision appraisal
1 finding
moderate“We identified gaps in staff supervisions as no staff were consistently receiving supervision in line with the providers policy.”
staffing levels
1 finding
moderate“People who required 2 carers not always having this.”
missed or late visits
1 finding
moderate“Our analysis highlighted timekeeping issues, including examples where care workers were not logging calls correctly.”
safeguarding
1 finding
moderate“They were not always following their policy as they did not notify the CQC of a recent safeguarding concern.”
incident learning
1 finding
moderate“The registered manager was not always analysing themes and trends to prevent reoccurrences.”
cultural competency
1 finding
minor“People's diverse needs, including religion, culture and language, were not assessed as part of the care planning process.”
communication with families
1 finding
minor“People using the service and their relatives were not always involved in developing their care. Care plans were not stored in people's houses.”