moderate“People's records did not always identify or assess risks...we found little improvements had been made.”
moderate“People's records did not always identify or assess risks, for example with moving and handling, falls, choking, and specific health conditions.”
moderate“Care plans lacked personalised information about how people liked to be supported, what they could do independently and where they needed support.”
supervision appraisal
2 findings
moderate“Staff told us they had not received regular support in their roles in the form of supervisions and appraisals.”
minor
“Because the service was new, the registered manager had not yet introduced regular supervision or annual appraisals.”
governance
2 findings
critical“The provider did not provide evidence of auditing since our previous inspection. Areas such as training, complaints, medicines management or safeguarding had not been reviewed.”
moderate“The registered manager and care coordinator were responsible for completing a variety of audits...however, due to only being registered for six months, this process had not been started yet.”
record keeping
2 findings
moderate“We were unable to view 2 out of 3 staff training records as we were informed records had been accidently deleted.”
moderate“Staff records were also missing some information regarding recruitment...Staff told us they had been to staff meetings, however none of these had been recorded.”
medication management
1 finding
critical“One person's medicines were being given irregularly but not recorded on a medicine administration record (MAR).”
safeguarding
1 finding
critical“We identified several incidents that could potentially involve safeguarding, but this had not been recognised by staff.”
infection control
1 finding
moderate“One person said, 'Staff wear a uniform, never seen them with gloves on.' Relatives fed back that staff did not always wear full PPE.”
staff training
1 finding
moderate“One relative said, 'One staff member didn't even know what dementia was. They do have 1 or 2 nice carers who just don't have the experience.'”
staff competency
1 finding
moderate“There was no evidence of competency checks to check staff understanding of their roles and responsibilities, such as with medicines management.”
staffing levels
1 finding
minor“One staff member said 'We work long hours with not much help. There is a shortage of staff to cover calls so taking time off is difficult.'”
leadership
1 finding
critical“There had not been a registered manager at the service for 13 months. The provider had a leave of absence due to ill health for 3 months prior.”
incident learning
1 finding
critical“The provider had not reported all notifiable incidents to CQC.”
complaints handling
1 finding
moderate“Allegations from people of staff bullying had been discussed in a staff meeting. There was no other evidence to show that this had been managed.”
consent capacity
1 finding
moderate“Staff lacked confidence and understanding regarding their responsibilities under the mental capacity act, including need for legal documentation for power of attorney.”
person centred care
1 finding
moderate“People's care documentation was not person-centred nor reflective of their current support needs.”
communication with families
1 finding
minor“A person and relatives told us they had not been asked for their views on care, nor had they been involved with regular reviews.”
other
1 finding
moderate“We found that the service did not have a contingency plan to manage emergencies, such as adverse weather conditions or staff sickness.”