critical“Safeguarding logs received from the provider did not include all incidences of alleged abuse the CQC had been informed of from the local authority.”
medication management
1 finding
critical“For some medicines the strength, formulation, route and start date were missing from the MAR and handwritten instructions relating to medicines was not legible.”
care planning
1 finding
moderate“Some people's care plans had not been updated to reflect changes in their care needs. For example, one person's mobility had declined, and they were no longer using a hoist.”
staff training
1 finding
critical“Specialist Motor Neurone Disease (MND) training had not been completed by staff, despite professionals trying to organise this with the provider on at least 4 occasions.”
staff competency
1 finding
critical“Most staff providing care had not received training in PEG care. Competency checks are the responsibility of the healthcare professional who has delegated this healthcare task.”
governance
1 finding
critical“The providers governance systems to monitor the quality and safety of the service were not effective. A Warning Notice was issued for breach of Regulation 17.”
record keeping
1 finding
moderate“Various care records were not signed or dated. Some consent to care records were missing. The daily record audit for 2023 did not record any actions.”
incident learning
1 finding
moderate“The provider had failed to effectively monitor the performance of the service. Safeguarding concerns had not always been recorded, meaning patterns and trends could not be identified.”
leadership
1 finding
moderate“At the time of our inspection there was not a registered manager in post. A new manager had been in post since 11 April 2023 and had applied for their DBS.”
person centred care
1 finding
minor“People's religious beliefs and cultural considerations were not detailed in their care plans or care needs assessment.”
communication with families
1 finding
moderate“One relative said, 'The manager does not reply to emails, and there is poor communication from them, nobody gets back to us.'”
consent capacity
1 finding
minor“Not all care records contained a record of consent in relation to care, records or sharing of information.”