critical“Medicine records for as required medication lacked detail for people, eye drops and creams were not always effectively managed as well as risk assessments required for prescribed creams.”
critical“Training matrix record showed that the training course for medication administration was completed the same day as 18 other courses for much of the workforce.”
staffing levels
2 findings
moderate“We found on two consecutive visits that the rotas were not complete for the following week, and this was corroborated by discussions with staff.”
moderate“For some staff, we found excessively long shifts from early morning till later at night. This was evidenced by rotas and staff interviews.”
safeguarding
1 finding
critical“Records held with the provider and the safeguarding referrals made to the local authority were not always reported by way of notification to CQC.”
incident learning
1 finding
critical“A person's care plan and risk assessment were not updated after an incident that had occurred.”
care planning
1 finding
critical“Risks had not been sufficiently assessed or mitigated and care plans were not always in place to guide staff on how to keep people safe.”
staff training
1 finding
critical“Induction training was completed on the same day for a large percentage of staff, this was a total of 18 courses for 47 staff members out of 57.”
supervision appraisal
1 finding
moderate“Staff did not have regular supervision or appraisals of their performance. Staff told us they could not recall the last time they spoke with the registered manager.”
governance
1 finding
critical“The provider's system did not always effectively monitor the quality of care provided to drive improvements.”
staff competency
1 finding
moderate“Staff were not always recruited safely. We found that recruitment and induction processes were not robust.”
missed or late visits
1 finding
moderate“Reports of staff being late, frequent breakdown of staff vehicles and staff changes without informing the person or the family member.”
person centred care
1 finding
minor“The provider was unable to evidence annual survey engagement and feedback improvement plans, from people or their families.”
record keeping
1 finding
critical“People's care records and risk assessments were not reviewed after an incident.”