critical“We've had a lot of problems with missed visits and late calls. There are times when they just don't come. If the carers don't visit it means [my person] doesn't get a wash.”
critical“There was not a robust system in place to monitor missed and late visits effectively. Whilst an electronic process was in place the registered manager told us staff were not using the system correctly.”
safeguarding
2 findings
critical“There was also still no meaningful analysis of safeguarding themes and trends. The provider had failed to reduce the risk to people and learn lessons from incidents.”
critical“The local authority had received several complaints in relation to missed calls and these were raised as safeguarding's. None of these safeguarding's had been reported to CQC by the provider.”
governance
2 findings
critical“Audits carried out were not effective, and there was no clear action plan linked to observations made. No entries for nine care visits over eight days with no follow-up.”
critical“Systems and processes were not robust enough to demonstrate quality and safety were effectively managed. This placed people at risk of harm. This was a breach of regulation 17 (Good Governance).”
record keeping
2 findings
moderate“Records were not always completed, which meant changes to people's care needs might be missed. Poor record keeping also created a risk people were not receiving enough to eat and drink.”
moderate“People's care notes were not always being completed on all visits. This meant the care team did not always have access to the latest information to reflect people's changing needs.”
staff competency
2 findings
critical“Staff files did not always demonstrate the provider had checked staff were safe and suitable for the role. Gaps in employment history not explored, references not completed.”
moderate“Three staff we spoke with could not tell us who to report to externally. A staff member told us, 'I would report any concerns straight to the manager.'”
person centred care
2 findings
moderate“I have no rota. I have no idea who is going to come and at what time. They try to rush me, and I have to tell them to stop and wait because I'm out of breath.”
minor“Some staff stay the full amount of time, but some do what they need to then leave.”
complaints handling
2 findings
moderate“The provider did not carry out any analysis of themes and trends in complaints, to demonstrate how they acted to improve the service in response to people's feedback.”
moderate“Complaints had not always been appropriately investigated to make improvements and prevent a reoccurrence. There was no outcome or action recorded.”
incident learning
2 findings
critical“Lessons had not been learned from the previous inspection and numerous shortfalls had not been addressed. Limited action had been taken to resolve shortfalls identified at the last inspection.”
moderate“No related themes or trends had been explored in relation to these concerns at the time they were raised.”
staffing levels
1 finding
critical“There are not enough staff here and there haven't been enough for a while. There are definitely not enough staff.”
supervision appraisal
1 finding
moderate“Staff told us they were not always given regular formal supervisions. One care worker said, 'I do not know what a supervision is, and I don't think I have ever had a 1:1 with my manager.'”
infection control
1 finding
moderate“Some care workers did not wear PPE in a way that followed government guidance, and people we spoke with were not confident staff always washed their hands.”
consent capacity
1 finding
moderate“There was no evidence of formal capacity assessments or detailed best interests decision making within the care plans of people living with dementia.”
medication management
1 finding
moderate“As the notes were not being consistently completed it was not always clear whether people had taken their medicines as prescribed. We found a tablet on the floor.”
leadership
1 finding
critical“The provider could not demonstrate oversight of the quality and safety of the service. This had led to the local authority commissioners placing a suspension on the service.”
care planning
1 finding
moderate“Two people's assessments did not always contain all the information staff required to meet people's needs. For example, guidance on supporting two people with epilepsy.”