critical“There were few quality assurance and governance arrangements in place, such as audits, to monitor the service.”
critical“systems in place to monitor the quality and safety of the service were not effective. This placed people at risk of harm. This was a continued breach of regulation 17”
moderate“During the inspection we found the notification had not been sent to CQC. We spoke with the registered manager, they assured us that this was an oversight due to a recent period of absence.”
critical“The checks of the safety and quality of the service had not highlighted all the issues we found during this inspection. Effective arrangements were not in place to assess and monitor quality.”
record keeping
4 findings
moderate
“Recruitment practices were not as robust as they should be, and improvements were required. The provider could not demonstrate all records relating to staff's employment had been sought.”
moderate“Risk assessments were not always in place to ensure staff had guidance to support people safely and care plans were not always up to date or reviewed”
minor“The registered manager recorded all communications from people in a bound book; this meant it was not always easy to assess different communications in relation to late visits.”
moderate“Care records were not consistently personalised, nor did they contain all the knowledge from staff working with them at each care call.”
staffing levels
3 findings
moderate“Concerns were raised with us by 1 person to imply there may not always be enough staff to support their family member to stay safe.”
moderate“They are not always on time and there's no consistency. I keep getting agency workers and they are always rushing.”
critical“The provider had failed to ensure sufficient staff were deployed to meet people's needs. This demonstrated a breach of Regulation 18 of the Health and Social Care Act 2008.”
staff training
3 findings
minor“action was required to ensure staff received appropriate training relating to people with a learning disability and autistic people.”
moderate“Training records evidenced staff had not had refresher training in key areas including medicines management, safeguarding and moving and handling.”
moderate“24 staff out of 30 staff had not received a safeguarding refresher in the last three years. Other subjects such as MCA and DoLS and dementia had not been refreshed for staff since their start date.”
missed or late visits
3 findings
minor“people were not always notified of changes to staff or visit times.”
moderate“It's their timing of arrivals that I have the problem with. I'm often sitting around past my time slot waiting for them to arrive.”
moderate“Fifty percent of people we spoke with had experienced changes to the timings of their visits... there was not a robust system in place to monitor missed and late visits effectively.”
complaints handling
2 findings
moderate“people told us where they had raised a concern with the manager, their concern had not been responded to and they were still awaiting a response.”
moderate“it was not always clear what actions had been taken in response. For example, where a concern had been raised about one carer's use of PPE, no action was recorded.”
medication management
2 findings
critical“one person needed to sit upright for 30 minutes following administration of their medicine. This information was not on their most recent MAR chart”
critical“We found numerous gaps on the MAR's and some of the records went back to 2018. When we asked for the audits to identify if the gaps had been investigated we were told there were no recent audits.”
care planning
2 findings
critical“one person's assessment stated they had epilepsy; however, no epilepsy guidelines or risk assessment was in place for staff to follow in case the person had a seizure.”
critical“People's care plans did not give information to staff about their personalised care needs such as dementia, diabetes or mental health. Care plans we reviewed had limited information.”
consent capacity
2 findings
moderate“People's consent to care had not always been clearly recorded in their care plans. A number of care plans contained blank or incomplete consent forms.”
critical“The registered manager was not working within the principles of the MCA... had not considered what decisions people could make for themselves and had asked family to consent.”
communication with families
2 findings
minor“They don't let me know of any changes, they don't phone me at all.”
minor“I did have a regular carer, but she has recently been off ill and I'm getting a little messed around at the moment with different carers – I wish they'd phone me to tell me who is coming.”
supervision appraisal
1 finding
moderate“There was no evidence to demonstrate the previous provider had completed formal supervisions and 'spot visits' for staff.”
end of life care
1 finding
moderate“The provider's assessment process did not consider whether people had any specific wishes for their future end of life care.”
staff competency
1 finding
moderate“The provider's system for monitoring staff knowledge and competency was not robust and had not highlighted the gaps in staff training.”
infection control
1 finding
minor“The provider had not ensured all staff had up to date infection prevention and control training... this was not in place for all staff.”
person centred care
1 finding
moderate“People's care plans held either little or no information about people's likes, dislikes and preferences. There was no information in people's care plans about their life history.”
incident learning
1 finding
moderate“The registered manager told us the usual process for missed calls would be to complete an incident form, but this had not happened.”