moderate“records relating to people's care, the management of some risks and medicines and the recruitment of staff were not always complete, contained conflicting information, or were not fully up to date”
critical“A lack of robust record keeping meant medicines were not always managed safely.”
critical“changing records retrospectively could increase the risk of medicine errors occurring as the manager would not be able to identify and actions errors with staff”
critical“A lack of robust record keeping meant medicines were not always managed safely... records were not maintained in line with legislation and regulations”
care planning
4 findings
moderate
“It was not always clear on people's health conditions in their care plans. This meant someone could be living with an illness or condition that staff may not be aware of”
minor“Falls risk assessments still needed to be more robust, for example, one person had experienced some recent falls...the person's falls risk assessment had not been updated”
critical“some areas of risk had not been assessed and not all records were completed fully... There were still no risk assessments for people living with dementia.”
critical“We found five people without a basic care plan. This meant staff would not have appropriate guidance on how to support people safely”
governance
4 findings
moderate“further work was required to embed these systems to ensure they were fully effective”
critical“There was a clear lack of management oversight at the service. We were still not assured that regulations were followed and understood fully.”
critical“There were no regular checks or audits completed by the manager of the service.”
critical“The nominated individual did not have systems in place to effectively assess, monitor and improve the quality and safety of the service provided. They did not carry out any audits”
medication management
4 findings
minor“One person's records showed there was not always a 4 hour gap in-between doses for pain management. The provider acted straight away to address this.”
critical“we found gaps in people's MAR's which had not been identified and followed up. This meant it was not clear if people had not received their prescribed medicines”
moderate“'When required', or PRN protocols in people's care plans were not always available and did not always include enough information to ensure medicines could be given safely.”
critical“Medicines were not managed safely... some of the MAR records had missing signatures... one person was having medicines administered through a feeding tube without a MAR chart in place”
leadership
3 findings
moderate“There was no registered manager in place. However, the provider who was the manager of the service had completed their application to be registered with CQC”
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
critical“There was a lack of positive leadership and guidance in the service which had led to care that was not person-centred... The nominated individual had no oversight of the service”
staff training
3 findings
minor“Staff were required to complete safeguarding training...Records showed all staff had completed training on safeguarding, although in a small number of cases, this had expired.”
moderate“no practical training was in place for manual handling just training online. This could people at risk and was not in line with health and safety legislation.”
critical“Staff had not received all of the training relevant to their role... not all staff had received training on manual handling... only the nominated individual and the human resources manager had received safeguarding training”
supervision appraisal
2 findings
moderate“for two staff members we could see no supervision records... We did not receive any evidence that these had taken place.”
moderate“We did not see any records that showed staff were provided with supervisions (one to one meetings) with their line manager”
incident learning
2 findings
moderate“We could not be assured the service was learning lessons when accidents and incidents occurred. There were no records to support this or track any incidents.”
moderate“we could not be assured at the time of inspection that lessons had always be learnt when things had gone wrong... we could not be assured that effective processes were in place to review and identify learning”
end of life care
2 findings
minor“there was no training in place for staff to support staff if they did take on anyone with end of life care.”
minor“When we visited the service, nobody was receiving end of life care. However, staff had not received training on end of life care”
consent capacity
2 findings
minor“While consent forms were in place some records regarding medicines consent were missing.”
moderate“Records showed that not all staff had received training on the MCA and we were unable to speak to staff about their understanding”
staff competency
1 finding
moderate“in two of the staff files there were gaps in employment history... In another staff file there were only character references and no recent employment reference”
complaints handling
1 finding
minor“the service was not keeping any formal records of complaints just emails on the computer which were difficult to track”
staffing levels
1 finding
critical“The provider had failed to deploy sufficient numbers of staff in order to meet people's needs and keep them safe. This was a breach of Regulation 18”
person centred care
1 finding
critical“Failure to ensure people receive person-centred care and treatment that meets all of their needs is a breach of Regulation 9”
safeguarding
1 finding
critical“New staff had not received any safeguarding training as part of their induction... the service could not demonstrate how they had assured themselves staff understood safeguarding”
missed or late visits
1 finding
moderate“Carers arrive at various times. Very random visits... They have been three and a half hours late... There was one missed call”
infection control
1 finding
moderate“not all staff had received training on infection control and uniforms were not always worn”
other
1 finding
critical“The failure to have safe recruitment procedures was a breach of Regulation 19... DBS checks... only in place for two staff members”
communication with families
1 finding
moderate“The provider had not sought feedback from people or their families through the use of a quality assurance survey”