minor“the complaints log had not been fully updated with the actions taken in response to complaints”
minor“information about accidents and incidents had not been consistently documented in line with the provider's policy”
critical“The service had failed to maintain securely an accurate, complete and contemporaneous record in respect of each service user.”
governance
2 findings
moderate“further examples of notifications which had not been reported to CQC in line with requirements”
critical“Management systems were not operated effectively to assess, monitor and improve the quality and safety of the services provided”
medication management
2 findings
moderate“one incident where an omission of medicines had not been appropriately reported to the local safeguarding authority”
critical“The service had not ensured the proper and safe management of medicines, including record keeping of the administration of medicines.”
communication with families
2 findings
minor“A lot of the newer carers can't even speak English properly. Sometime they have to get things translated”
minor“There is a language barrier, most have English as their second language and then they are wearing masks.”
end of life care
1 finding
minor“7 staff who had been employed prior to June 2022 had not yet undertaken the same [palliative and end of life care] training”
safeguarding
1 finding
critical“The service had failed to implement effective systems to identify, investigate and appropriately respond to allegations of abuse.”
care planning
1 finding
critical“Risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient detail to help staff understand and respond to risks.”
infection control
1 finding
moderate“Records did not evidence staff uptake of COVID-19 tests... This could have placed people at increased risk from COVID-19 infection”
incident learning
1 finding
moderate“There was no evidence the service had undertaken a monthly analysis of accidents and incidents to identify where further action may be required to prevent reoccurrence.”
staff competency
1 finding
moderate“Processes for staff competency assessments, spot checks and supervisions had been inconsistently implemented.”
staff training
1 finding
moderate“existing data indicated no staff members had completed diabetes awareness or epilepsy awareness training... only three staff had completed managing behaviour training, and end of life care training.”
supervision appraisal
1 finding
moderate“The staff member's first supervision had been carried out in November 2021, several months after commencing employment, and the meeting had been conducted by a colleague, not the person's supervisor.”
consent capacity
1 finding
critical“Effective systems were not operated to ensure the service worked in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.”
person centred care
1 finding
critical“Processes for assessing and reviewing people's needs were not fully effective in ensuring care met people's needs and preferences.”
complaints handling
1 finding
critical“Systems were not operated effectively for identifying, receiving, recording, handling and responding to complaints.”
staffing levels
1 finding
moderate“Records showed staff often stayed less than scheduled visit times, staff were not always provided with sufficient travel time on rotas”
missed or late visits
1 finding
moderate“Their time keeping is terrible... they don't let me know...I don't know when they are supposed to come as I don't see the rota…there is no fixed time…they can come very late”
leadership
1 finding
moderate“The service had not demonstrated improvements following an audit conducted by the franchise head office in February 2021.”
other
1 finding
critical“Systems were not consistently operated for the safe recruitment of staff.”