critical“The registered manager had not operated an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.”
medication management
1 finding
critical“We were not able to check any records for management of medicine such medication administration record (MAR) sheets and any 'when required' PRN medicine protocols.”
staff training
1 finding
critical“Staff were not provided with training and skills to ensure they had the right knowledge and guidance to provide effective care and support to people.”
staff competency
1 finding
critical“The registered manager confirmed staff did not have their competencies assessed such as for medicine and moving and handling.”
staffing levels
1 finding
critical“One member of staff had only stayed 12 minutes instead of an hour on more than one occasion... calls had been missed... missed a number of bedtime calls during the last month and had not eaten one night.”
missed or late visits
1 finding
critical“This morning they were extremely late... received no contact about the late visit... first care visit that morning had been at lunch time. There had been no calls to say that staff would be late.”
record keeping
1 finding
critical“The registered manager did not always ensure that clear and consistent records were kept for people who use the service and the service management.”
supervision appraisal
1 finding
moderate“Only some staff had only one session of supervision to review their performance, professional development and discuss any matters.”
complaints handling
1 finding
critical“There were no clear records completed for two complaints. The forms used to log the complaints were blank... at least two more complaints, however there were no records found during inspection.”
care planning
1 finding
moderate“Most parts in the care plans had basic information and did not include more detailed information for staff to follow, so they could meet specific people's needs safely and effectively.”
incident learning
1 finding
critical“The registered manager did not make a record of further actions needed to be taken to mitigate risk to individuals... unable to check the outcomes of investigations and any action taken.”
safeguarding
1 finding
critical“The registered manager did not ensure CQC was consistently notified of at least six reportable events such as allegation of abuse within a reasonable time frame.”
consent capacity
1 finding
minor“Some of the care and support records were signed by the family members and it was not clear if they had a legal right to do that.”