critical“Staff were administering medication without appropriate training or checks of their competency.”
critical“Handwritten medicine records were not always checked by another member of staff to ensure they were correct and included all required information.”
critical“one person's medicine protocol referred to two different medicines and it was unclear how much medicine should be administered.”
missed or late visits
2 findings
critical“The providers call monitoring system identified multiple missed and late visits. This meant that people were at risk of harm by not having their care and support needs met.”
moderate
“People continued to receive late care calls and monitoring systems had not resolved this shortfall.”
safeguarding
2 findings
critical“we identified two concerns of potential financial abuse and three concerns of neglect. We raised safeguarding alerts in respect of our findings with the local authority safeguarding team.”
minor“records did not always show when this was completed, or the advice received. Monitoring systems required improving to ensure records demonstrated action taken.”
staff competency
2 findings
critical“one member of staff had worked without supervision before the recruitment process had been completed.”
moderate“Records were in place but were not always fully completed with the assessment date or staff signatures.”
record keeping
2 findings
critical“people's daily records were not always completed. This lack of review meant concerns about people's care and support needs were not always known and responded to.”
moderate“Competency and spot checks had been implemented... Though records were not always dated or signed by the staff member which meant it was unclear when they were last assessed.”
incident learning
2 findings
critical“The provider had no systems in place for recording of incidents or accidents. Accidents and incidents were not monitored.”
moderate“An appropriate system to monitor and learn from accidents and incidents was not in place. There was no evidence of analysis or learning from accidents and incidents.”
governance
2 findings
critical“The provider had failed to implement and operate effective systems to monitor the quality and safety of the service.”
critical“Quality assurance systems had not identified or addressed the shortfalls identified during the inspection.”
infection control
1 finding
critical“The providers policy for COVID-19 had not been updated to reflect government guidance or best practice guidance.”
staff training
1 finding
critical“Staff had not received any training in relation to the donning and doffing of PPE.”
staffing levels
1 finding
critical“The provider had failed to ensure that there were sufficient numbers of staff deployed to meet the needs of people using the service.”
care planning
1 finding
critical“Risks to people were not assessed, recorded, managed and reviewed regularly.”
leadership
1 finding
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care”
communication with families
1 finding
moderate“They're always late. We get a phone call much later than the call time saying they are going to be late. I just expect it now.”
supervision appraisal
1 finding
moderate“There were no records of staff meetings and records relating of supervision did not demonstrate how the provider had engaged with staff to seek feedback and drive improvement.”
consent capacity
1 finding
moderate“People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests”
other
1 finding
moderate“We identified one incident that had not been notified to CQC.”