moderate“At our last inspection, quality assurance systems were not robust enough to identify shortfalls we found on risk assessments, care planning.”
critical“We found one person did not have a care plan. There was a referral form which was completed by a local authority.”
moderate“Care plans did not include the level of support people would require with nutrition. Information from care agencies and local authority for one person included important information.”
governance
2 findings
critical“Systems were not in place to ensure robust audits were carried out on care plans, risk assessments and ensuring staff attended calls in a timely manner.”
critical
“Audits had not been completed on care plans. The registered manager told us the last audit was completed in March 2022 and was archived.”
missed or late visits
2 findings
moderate“A relative told us, 'They do arrive on time. Timekeeping has improved. It was problematic before.'”
critical“Four relatives told us that time keeping was poor and staff can be late by over two hours. A relative commented, "Today (person) is just having lunch at 2:30pm, it should have been at 1:00pm."”
safeguarding
1 finding
critical“We found notifications of safeguarding allegation were not submitted to the Care Quality Commission (CQC) as is required.”
record keeping
1 finding
critical“We found incomplete records as risk assessments had not been completed in relation to people's health conditions. Care plan was not in place for one person and some were not up to date.”
supervision appraisal
1 finding
moderate“Regular supervisions had not been carried out for staff to ensure they were supported in their roles. The registered manager told us that supervision should be carried out monthly, but this was not formal.”
person centred care
1 finding
critical“Pre-assessments had not been carried out in detail to ensure the service was able to provide person-centred support to people.”