moderate“further improvements were required to ensure each 'as required' medicine had a protocol in place.”
moderate“further improvements were still required to ensure staff were given clear instructions on how to record and rotate the application of patches.”
critical“Medicines were not always managed safely. The provider did not have a system in place to ensure staff always recorded when people received their medicines.”
consent capacity
3 findings
critical“one person's family member had been asked to sign consent for their care and treatment on the person's behalf. This is not in accordance with the principles of the MCA.”
moderate
“where decisions needed to be made about people's care and welfare in their best interests, these decisions were not always recorded.”
moderate“one person's family members had been asked to sign consent for their care and treatment on the person's behalf. This is not in accordance with the principles of the MCA.”
communication with families
3 findings
minor“"If they [staff] are late we are not informed." People also told us they would like to have a copy of the call rota.”
moderate“some care staff did not have English as their first language. Where people had a hearing impairment or a cognitive impairment, this lack of communication caused anxiety.”
moderate“The provider was not aware of their legal responsibilities under the NHS's Accessible Information Standards.”
governance
2 findings
critical“governance systems were not established and did not always identify areas where improvements were required.”
critical“The provider failed to have oversight and governance systems were not established or effective. This placed people at risk of harm.”
missed or late visits
2 findings
moderate“"I am fed up with the poor timing of visits" and, "Staff just appear, the call times have not been followed."”
critical“One person received no care calls for 7 days, leaving them at serious risk of harm.”
incident learning
2 findings
moderate“staff did not always raise incidents with the registered manager when they occurred, so that incidents could be effectively investigated.”
critical“The provider failed to maintain accurate records of events which called into question people's safety, so that a review and analysis of these events could take place and lessons could be learnt.”
record keeping
2 findings
moderate“new governance processes had not identified there were improvements required in the areas of medicines management, safe recruitment practices, and the adherence to the MCA.”
critical“Records were not accurate or complete. For example, care records did not contain management plans and risk assessments relating to some people's specific needs”
complaints handling
2 findings
moderate“the majority of people told us they found it difficult to make contact with office staff if they had a concern about their care. One person told us it was, "Impossible to get through to the office."”
moderate“Complaints had not been managed in accordance with the provider's policy, because people had not received a record of the outcome of their complaint.”
safeguarding
1 finding
critical“We identified two allegations of abuse which had not been managed appropriately and had not been referred to the local authority safeguarding team or CQC.”
staff training
1 finding
critical“There were significant gaps in training for all staff and senior staff told us they had not received essential training required for their role when they started work.”
staff competency
1 finding
critical“The provider's records confirmed 24 staff had never received a medicine competency check, which placed people at risk.”
staffing levels
1 finding
moderate“the provider was unable to demonstrate whether there were sufficient numbers of staff to meet each person's scheduled care calls.”
leadership
1 finding
critical“The provider demonstrated no oversight of the service and told us they had carried out no quality assurance checks on the service since April 2021.”
care planning
1 finding
critical“people's care plans did not always include risk mitigation plans for people with specific health conditions, or guidance for staff about how to care for people safely.”
infection control
1 finding
moderate“Over 40 staff had not received training in safe infection prevention and control for over two years or had not received it at all.”
end of life care
1 finding
moderate“Records showed 167 staff had not received awareness training in end of life care. This included all senior staff apart from one.”
supervision appraisal
1 finding
moderate“The manager told us they had not received a one to one meeting with their manager to discuss their progress and development since they began their current role.”
person centred care
1 finding
moderate“there was no communication plan or assessment of risk in the person's care records, which meant staff were not provided with guidance about how to consistently meet the person's specific communication needs.”