critical“Failure to ensure effective systems are in place to monitor the quality and safety of the service...is a breach of Regulation 17 of the Health and Social Care Act 2008”
medication management
1 finding
moderate“Medicines were not always administered in line with people's plans of care...staff had left medicines for the person to take later.”
record keeping
1 finding
moderate“Records regarding who a service was provided to, and staff employed, were not always maintained accurately as differing information was provided during the inspection.”
safeguarding
1 finding
critical“CQC had not been informed of all notifiable incidents, such as safeguarding concerns. Failure to notify the Commission of these events is an offence.”
missed or late visits
1 finding
moderate“There were incidents when they were up to 3 hours late. They didn't ring to tell me...The morning call can be anytime from 9.30-11.30.”
staff competency
1 finding
moderate“The new staff are terrified of the hoist, they don't know how to use it...Sometimes I have to explain to staff what to do, especially with the moving and handling equipment.”
staff training
1 finding
moderate“Despite the training recorded, people raised concerns about the knowledge and skills of some staff, particularly the more recently recruited staff.”
leadership
1 finding
moderate“Several new managers in the past year, which has led to a lack of communication, rota's being changed without notice and a lack of training.”
consent capacity
1 finding
minor“Information regarding Power of Attorney (POA) was not always clear within people's care files and when records stated this was in place, there was not always evidence to support it.”
incident learning
1 finding
minor“We were told team meetings had taken place, but these could not be evidenced as they have not been recorded.”