critical“Audits completed had not always identified the concerns we found on inspection. There was an overreliance on office staff to complete a number of quality checks.”
critical“There was not a robust quality assurance process in place to monitor and drive improvement regarding areas such as recruitment, staffing, accidents and incidents or training.”
critical“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service and staff.”
medication management
3 findings
moderate“We reviewed MAR charts and found a number of gaps. The registered manager did not ensure these omissions were reviewed appropriately.”
critical
“one person had missed their medicines over a 24-hour period, due to staff not ordering a repeat prescription in time. As a result, the registered manager raised a safeguarding referral.”
moderate“We identified missing signatures on one person's medicines administration records (MAR) over a number of months. There was no evidence provided to suggest the service had followed this up.”
staff training
2 findings
critical“New members of staff did not always receive key training by the provider. The registered manager relied on previous training staff had completed with other care providers.”
critical“The training matrix indicated staff had completed 20 e-learning courses in one day. This approach was not good practice and staff members retention of these courses would not be sufficient.”
staff competency
2 findings
moderate“There was no formal process for the provider to assess the effectiveness of the training staff had received to established if they had the necessary skills to care for people.”
critical“The service did not have an effective system to check the care workers competency to ensure they were skilled and experienced to safely support people.”
safeguarding
2 findings
critical“A staff member not attending a call, falsifying records, and not reporting a person's catheter being removed...had not been reported the local safeguarding team or CQC.”
critical“Recruitment systems were not in line with current legislation or the provider's policy to keep people safe from inappropriate staff working with them. This placed people at risk of potential abuse.”
incident learning
2 findings
critical“The registered manager lacked awareness of their statutory responsibilities in relation to safeguarding statutory notifications to inform CQC of certain safeguarding incidents.”
moderate“Systems and processes for accidents and incidents was not robust and could not be accessed when we visited the service due to a computer glitch.”
leadership
2 findings
moderate“The registered manager was not available for the 2 days we visited their office...The provider failed to submit this action plan.”
moderate“There were periods where the service lacked leadership or management oversight. The registered manager was also the director of the care agency.”
record keeping
2 findings
moderate“Information such as accidents, incidents and training information were not always readily available to view on site.”
critical“References from previous employers were not always sought and application forms didn't always record the staff members full employment history.”
staffing levels
1 finding
critical“Staff continued to not be recruited safely, with gaps in employment histories and references not always being completed.”
supervision appraisal
1 finding
moderate“We found many supervision forms had been pre-populated and not discussed with the individual staff member.”
missed or late visits
1 finding
critical“The carers arrive at any time, I do not have a set time. In the morning they come as late as 10.00 or 11.15am, I am awake, but I have to wait for the carers to get me up and to get my breakfast and I am hungry.”