critical“we observed one person being supported by staff with medication, but there was no medication administration record. At another setting, medicines were stored in an unlocked wardrobe”
critical“across all 7 settings we visited we found discrepancies with the amount of medication in place compared with what their records stated they should have.”
staffing levels
2 findings
critical“one person should have received 56.5 hours over a week but had only received 49 hours”
critical“One service continually under delivered on the commissioned hours by significant amounts. Some staff worked 57 and 59 hours in a week.”
governance
2 findings
critical“The provider had completed quality audits, but these were not effective and did not drive the required improvements.”
critical“Systems and processes for monitoring quality and safety were not implemented effectively. Issues we identified had not been addressed prior to inspection.”
incident learning
2 findings
critical“one person had three falls in August 2022 and was admitted to hospital after the third fall. The person's risk assessment and support plan had not been reviewed”
critical“after a person had been subject to a serious incident, the incident form had not been completed with actions taken and mitigation for future occurrences.”
person centred care
2 findings
moderate“one person's care records stated they liked to assist staff to do the household weekly shopping. Staff confirmed the person did not participate in the household shopping”
moderate“1 person confirmed the only day they could go out was on a Monday due to the service not having enough staff who could drive, contradictory to the support plan.”
care planning
2 findings
moderate“one person had a personal choice record which was detailed and specific but had not been reviewed since March 2018 and was out of date.”
critical“The provider had failed to maintain contemporaneous care records and we saw conflicting information in some people's care records, and missing information in others.”
communication with families
2 findings
moderate“A relative raised a concern with us because the service had not involved them in developing the person's care and support.”
moderate“I used to be involved in reviews but there hasn't been one for the past 3 years. I don't have a date for one in the future.”
record keeping
2 findings
moderate“at one setting, there were missing sections of care records. At another setting, daily records lacked evidence of a person-centred approach.”
moderate“care documents were still not consistently accurate, and some were missing important risk assessments. The providers audit system had failed to identify these discrepancies.”
staff training
2 findings
moderate“Staff told us they had received appropriate training, but we did not receive training records to confirm this.”
critical“basic life support training had only been completed by 24.7% of staff. This meant the provider only had evidence 58 staff out of 234 had completed basic life support training.”
safeguarding
1 finding
critical“The provider had failed to tell CQC about significant events such as allegations of abuse, which meant they did not fulfil their legal responsibility”
leadership
1 finding
critical“Leaders did not have the knowledge, experience and oversight to lead a safe service. This placed people at increased risk of harm.”
infection control
1 finding
minor“we saw several examples where staff were not wearing face masks even though national guidance stated these should always be worn.”
consent capacity
1 finding
moderate“staff restricted the number of cigarettes this person could have, without a capacity assessment or best interest decision to support this action.”