critical“A lack of robust governance systems meant there was no oversight, routine quality assurance processes or audits to monitor the safety and quality of care.”
moderate“checks were not always carried out at the frequency of the provider's policy which meant oversight and monitoring was yet consistent.”
consent capacity
2 findings
moderate“Mental Capacity Act assessments were not carried out for people identified as potentially needing them and families were directed to the G.P to request this.”
minor“We identified some improvements to these records were needed to ensure they included evidence to support decision making.”
leadership
2 findings
moderate“I don't feel very supported by management as everyone that is higher up are either friends or family so they protect each other and not staff.”
moderate“the registered manager and director continued to cover calls in response to staff sickness. This impacted on the time they had available to manage the service.”
incident learning
2 findings
minor“We have learnt about whistleblowing but I feel that when we put concerns across they are not dealt with and the problem is still ongoing.”
critical“A recent safeguarding concern had been referred to the local authority but not us, CQC. In response to our inspection, a retrospective notification was submitted.”
safeguarding
1 finding
critical“A safeguarding concern had not been reported to the local authority or notified to CQC as required.”
care planning
1 finding
moderate“Some risks to people's health and safety were not assessed or guidance included in care plans. This included risks relating to catheters and people at risk of skin breakdown.”
record keeping
1 finding
moderate“There were unexplained gaps in some of these charts so it was unclear whether people were offered drinks on that day or the amount consumed.”
staffing levels
1 finding
moderate“Management spent a lot of time providing care calls which impacted on their ability to manage and oversee the service.”
medication management
1 finding
moderate“Some people were prescribed medicines on an 'as required' basis for pain relief. There were no protocols to support the administration of these medicines.”