critical“The management of medicines was not always safe. The systems in place to mitigate risks with the administration of medication were not robust.”
critical“One person's medicines were secondary dispensed... This practice was not risk assessed and there were no written procedures for staff to follow to mitigate possible risks.”
care planning
1 finding
critical“People's needs and risks had not been adequately assessed and care plans had not been updated appropriately, when people's needs and visit preferences had changed.”
missed or late visits
1 finding
moderate
“People's visits times did not always correspond with the visit times they had agreed with the service. Visits were sometimes much later or earlier than agreed.”
record keeping
1 finding
critical“Records relating to the length of time staff spent providing support to people, were also not accurate... visit records showed visits lasted less than 5 minutes.”
governance
1 finding
critical“The governance arrangements in place to audit the quality and safety of the service were not sufficient. The systems in place were poor and ineffective.”
leadership
1 finding
critical“There was little evidence that the provider had oversight of the service... neither the manager or provider of the service were able to explain the failings of the service.”
safeguarding
1 finding
critical“the provider had failed to ensure appropriate checks on the suitability of this person had been undertaken prior to appointment. This placed people at unnecessary risk.”
infection control
1 finding
moderate“the frequency of staff testing did not comply with government guidance, in place at the time of the inspection.”
staffing levels
1 finding
minor“the manager told us the service was currently experiencing staff shortages. A recruitment drive was underway.”
communication with families
1 finding
moderate“there was however little evidence that any regular care reviews took place to ensure people's care continued to meet their needs”
other
1 finding
critical“The provider had failed to notify CQC of the local authority investigation into the recruitment and safeguarding concerns... did not demonstrate they had a clear understanding of their duty of candour responsibilities.”