critical“The manager told us that no safeguarding issues had been raised by the service however we were told by the local authority that four had been raised in the past 18 months.”
medication management
1 finding
critical“MAR just documented numbers, not the actual name of the medicines. Staff were not able to tell us about the side effects some medicines may create.”
care planning
1 finding
moderate“Sections within care plans were headed 'About me' but in all cases these were blank. Care plans were not person centred.”
staff training
1 finding
critical“A person had a PEG feed through which medicines were administered. No staff at that time had received training in this area.”
governance
1 finding
critical“There were no auditing processes in place and quality assurance processes were inconsistent with no analysis of the views of people or their relatives.”
incident learning
1 finding
critical“Not all accidents and incidents had been recorded. One incident had been recorded in the past 12 months... no steps had been taken to minimise the risk of similar events.”
supervision appraisal
1 finding
moderate“Supervision meetings were inconsistent, and few records kept. We were shown team meeting agendas but no minutes or actions were recorded.”
consent capacity
1 finding
critical“There were no mental capacity assessments (MCA) in place for people needing help with making decisions.”
end of life care
1 finding
moderate“There were no end of life care plans in place for people. Staff had not been trained in end of life care.”
person centred care
1 finding
moderate“Some people told us that they had requested female carers but this had never been provided despite repeated requests.”
missed or late visits
1 finding
moderate“"I have one half hour visit, they are here for 20 minutes" and "I'm being billed for 45 minutes and I get 20 minutes."”
complaints handling
1 finding
minor“Not everyone knew how to raise issues or make a complaint. A person told us, "No I don't know who to contact. That's why I'm writing to the council."”
leadership
1 finding
critical“The service had had four registered managers in the last 18 months, all of whom had left. The manager had not notified CQC of incidents they were legally obliged to.”
record keeping
1 finding
moderate“We saw gaps where medicines had not been recorded as being given although care notes recorded that they had.”
cultural competency
1 finding
minor“Care plans had a section called 'About me.' However, these sections were blank... no details of people's cultural or spiritual needs recorded.”
communication with families
1 finding
minor“"Their English is not amazing but they are comfortable with them now" and "there is a communication barrier on both sides."”