moderate“One staff file didn't have a reference from their most recent employer or an explanation of why although they did have 2 references in place.”
moderate“failure to have clear and concise records in all areas to monitor and manage the service was a breach of regulation 17 (Good Governance)”
communication with families
2 findings
moderate“People spoken with told us they didn't receive a rota, their regular care staff didn't always come for the visit and they weren't told who was coming.”
minor“Someone sat down with [name] four weeks ago, didn't tell us it was a review.”
governance
2 findings
minor“we did not find clear evidence of learning from incidents, how this was shared with the staff team and used to improve care.”
critical“Failure to ensure effective systems and processes were in place to assess, monitor and improve the quality and safety of the services provided to people.”
person centred care
2 findings
minor“Care plans contained little information to guide staff in relation to respecting and promoting people's privacy and dignity.”
moderate“One person told us their support was not at a time that supported their choice and they had been told they could not change this, this was not person-centred.”
medication management
2 findings
critical“Medicines were not always administered and managed safely... There was crossing out making information unclear. The records were not always initialled by staff who had given the medication”
critical“Relative has meds three times daily, carers do give meds but visits vary so greatly, meds are often not given on time. We have had issues with tablets not being given, finding tablets on the floor.”
other
2 findings
critical“Staff were not always recruited safely. There were documents missing from the recruitment process including a second reference and proof of identity in one file.”
critical“The provider had not always made the necessary notifications to the CQC, and other agencies, when relevant incidents had occurred.”
staffing levels
1 finding
moderate“gaps in employment history, which were not accounted for, in 2 out of 3 staff files reviewed.”
safeguarding
1 finding
critical“Failure to ensure effective systems and processes were in place to protect people from abuse and improper treatment. This placed people at increased risk of harm”
staff training
1 finding
critical“Staff training records identified not all staff had been trained in safeguarding adults.”
staff competency
1 finding
critical“Not all staff had received effective training in medication and been assessed as competent. One staff member told us they had not been assessed as competent to administer medicine.”
leadership
1 finding
critical“Management lacked oversight of the service because they didn't have the checks in place to be able to assure themselves staff were delivering good quality, person centred care.”
care planning
1 finding
moderate“more recent care plans were incomplete and lacked any person centred information about how the person liked to be supported.”
supervision appraisal
1 finding
moderate“In the last four months supervision was not being carried out regularly. Staff told us they did not receive regular supervision and the staff files reviewed supported this.”
incident learning
1 finding
moderate“The lack of oversight, actions and learning from incidents at the service demonstrated that the management team did not understand the principle of good quality assurance.”
complaints handling
1 finding
moderate“I do know what to do to raise a complaint, but don't have the confidence the agency follows up when concerns are raised. Not sure they have procedures in place to check up on things”
missed or late visits
1 finding
moderate“carers do give meds but visits vary so greatly, meds are often not given on time”
infection control
1 finding
moderate“we could not see evidence that all staff had effectively been trained in infection prevention and control, personal protective equipment and COVID-19.”
consent capacity
1 finding
minor“not all documents had been signed and dated, so there was a risk about the validity of these documents.”
end of life care
1 finding
minor“There were no end of life care plans in the documentation we reviewed.”