critical“Systems and processes were not established or operated effectively to assess, monitor and improve the quality and safety of the service.”
critical“Several medicines administration record audits had failed to identify inconsistencies in the use codes used by staff or relatives when people had their medicines omitted.”
critical“We found no systems in place to monitor and improve the quality of the service and no evidence of audits to drive continual improvement.”
care planning
3 findings
critical“there was no information about how one person's health condition meant some days they required more support than others and how their health condition affected them”
critical
“The assessments and task sheets were very basic and did not provide full information about people's needs nor full guidance for staff in how to support people in line with their preferences.”
minor“it was not obvious from people's care records when and who had been involved with the review and if they had agreed to the care plan.”
record keeping
3 findings
critical“a relative and staff informed us one person's care plan had been missing from their home for approximately one year”
critical“Disclosure and barring service (DBS) checks had been completed...However, two of these had been returned after the start date and there was no record that a holding check had been completed.”
moderate“We saw no evidence of references in any of the staff files we checked, which did not follow the registered provider's recruitment and selection policy.”
supervision appraisal
3 findings
moderate“The registered manager did not provide and document a record of staff supervision...two staff told us they did not feel supported.”
minor“we found there was no supervision or spot check schedule to ensure these were carried out at regular intervals.”
moderate“We were unable to see any supervision records held with staff at the service in the last year.”
incident learning
3 findings
moderate“Two people had falls recorded in the accident and incident folder. However, falls risk assessments had failed to be implemented following this.”
critical“Not having a quality monitoring system that was effective in highlighting shortfalls, so they could be addressed in a timely way, was a breach of regulation 17 (good governance).”
critical“They had provided some end of life care to several people who had passed away and confirmed they had not submitted any statutory notifications to CQC.”
medication management
3 findings
minor“There was a minor issue with confusion over codes when medicines were omitted. This was mentioned to the registered manager to address.”
minor“Where the service had produced their own MARs some information about people's medicines had not been signed by staff to show it was correct and accurate.”
minor“One person was receiving blood thinning medicine. There was no risk assessment in place to guide staff on how to manage the possible side effects of this medicine.”
staffing levels
2 findings
critical“The provider and registered manager had not requested any references or completed a DBS check for them. There was no evidence they had checked they had the qualifications, competence, skills or experience”
critical“Out of the six staff files we looked at, three people did not have references and two people had one reference, one of which was returned after their start date.”
person centred care
2 findings
moderate“there was also no information about people's current circumstances or life history, which is important so staff can have meaningful conversations”
moderate“One person's task sheet indicated staff were to 'make a meal'...'encourage [name] to assist with food preparation'. None of the tasks described how they were to be completed or what the person's preferences were.”
consent capacity
1 finding
moderate“there was no written documentation for people to sign consent to their care records...no system to document how consent would be obtained where people may lack capacity”
leadership
1 finding
moderate“Some staff felt they were not approachable...A member of staff said, 'I just don't think we are looked after properly.'”
staff training
1 finding
moderate“We found there was a lack of training in specific areas such as first aid, infection control and food safety.”
infection control
1 finding
moderate“None of the staff had received infection control training to assist in maintaining good infection prevention and control.”