moderate“Systems to monitor and assess the quality of the service were not always effective. Quality assurance systems had not identified the failure within the recruitment process.”
moderate“The issues relating to COVID-19 testing and monitoring of DBS checks had not been identified by them.”
critical“medicine audits were not routinely completed and discrepancies we found in recruitment files had not been identified”
critical“The provider had not always submitted the required statutory notifications to CQC. The provider was operating from an address not registered with CQC and had not informed us of this change.”
record keeping
3 findings
moderate
“Staff were extremely knowledgeable about how to keep the person safe, but this information was not reflected within the documentation.”
critical“provider failed to maintain accurate, complete and contemporaneous records and have effective systems to assess, monitor and improve the quality and safety”
critical“The provider did not ensure staff always maintained accurate and complete records. The manager was unable to provide us with a clear account of the actual number of people who were in receipt of personal care.”
staffing levels
2 findings
moderate“People were not always supported by a regular staff team. One relative told us, "At times we don't know who is turning up, sometimes agency staff who we don't know"”
moderate“One adult was supported by nine different staff members over a twelve-day period. Their relative told us this had a negative impact on their family member.”
staff competency
2 findings
critical“DBS certificates linked to the DBS Updating Service were not reviewed by the service prior to applicants starting work.”
minor“Documentation stated that all staff were checked monthly via the DBS updating service... we found one staff member had not received monthly checks.”
infection control
2 findings
critical“Staff were not completing weekly polymerase chain reaction (PCR) tests... not all staff were completing weekly LFT. This placed people at risk of harm.”
critical“Generic risk assessments indicated that people being supported could not tolerate staff wearing a face mask. Staff had not assessed individual needs or explored alternative solutions such as clear face masks.”
care planning
2 findings
moderate“Care plans and risk assessments did not reflect this depth of information.”
moderate“Children's care plans were not available in a format for them to understand. The provider had no systems in place to support the children's rights. Care plans were not regularly reviewed.”
incident learning
2 findings
moderate“these need to be sustained and further developments were still needed. The requirements of the warning notice have been partially met.”
moderate“Accidents and incidents were recorded and reviewed. However, outcomes and lessons learnt were not always recorded.”
person centred care
2 findings
moderate“provider failed to seek feedback from children about their care and support, and how the service was run”
minor“The provider did not have systems in place to gather the views of children, without the support of an adult either their relative or staff member.”
staff training
2 findings
critical“People did not receive care and support from suitably skilled and experienced staff. Some staff had not received training around people's specific needs. No specific training regarding the care and support of children was in place.”
minor“New staff had not completed an in-depth induction programme... it was brief. One staff member told us, "Induction was very brief, we went through some policies and procedures."”
communication with families
1 finding
moderate“Important conversations regarding people's care and support were not always recorded which led to confusion for people and relatives, which impacted negatively on the quality of care they received.”
leadership
1 finding
critical“Changes in the management team throughout the year had a negative impact on the running of the service. Quality monitoring was not completed.”