critical“The registered manager failed to report to CQC when they were made aware of a safeguarding concern where a person had their body hair shaved without seeking their consent.”
staffing levels
1 finding
moderate“Staff arrival times for care call visits varied by up to an hour. Relatives told us it was a regular occurrence that they were not alerted when staff were running late.”
staff training
1 finding
critical“Staff supported people with dementia, people with learning disability and autistic people, but they had little understanding about how to effectively support people.”
staff competency
1 finding
moderate“Staff had not had their competency assessed regularly and had no meaningful one to one support, supervision to discuss their performance, agree training needs.”
medication management
1 finding
critical“Relatives told us they found medicines on the floor or some medicines not administered as prescribed although staff signed to indicate they had administered these.”
governance
1 finding
critical“The lack of effective auditing of the service meant they failed to identify where improvements were needed around recruitment, training, supervision, keeping people safe.”
incident learning
1 finding
moderate“There was no analysis done by the registered manager to understand the nature of incidents happening across the service. They had not looked for trends and patterns.”
record keeping
1 finding
moderate“There were no records kept within the service to evidence that concerns were recorded, and actions were implemented to make the necessary improvements.”
consent capacity
1 finding
moderate“Some people's care records detailed they lacked capacity around their finances, personal care or understanding risks, however there was no MCA assessments in place.”
care planning
1 finding
moderate“Care plans did not give enough guidance to staff to know people's likes and dislikes or meal preferences. Risk assessments were not always clear or coordinated.”
supervision appraisal
1 finding
moderate“Some staff said they did not receive additional training in specific areas such as dementia, they had not received supervision and some staff had not received an appraisal.”
leadership
1 finding
critical“The registered manager failed to ensure they had a full understanding of their management responsibilities. They had little oversight of the service.”
communication with families
1 finding
minor“Relatives told us they had limited access to daily care records since these were electronic, therefore they felt less involved in people's care to support decision making.”