critical“lack of documented guidance for staff...some people were noted to be 'prone to falls', yet there were no identified associated risks”
critical“People's safety needs associated with their health conditions were not always effectively assessed or detailed in their care plan. We found not all risks were recorded.”
critical“People's care was not planned in a way to ensure their needs and preferences were being met.”
moderate“One person's care plan contained brief information which indicated they had a catheter. However, there was no information to identify the associated risks”
medication management
4 findings
minor
“there remained very little information for staff, such as detailed protocols [for 'when required' medicines]”
critical“The provider did not complete any medication audits for the electronic records. This meant they were not aware or managing discrepancies with medicines.”
critical“Systems and processes in place were not effective to ensure people received their medicines safely.”
critical“People were being supported by staff who had no recorded medicines training.”
record keeping
3 findings
critical“provider failed to ensure they kept accurate, complete and contemporaneous records in respect of each person”
moderate“Care plans shared with us had historic information in that was not relevant to the persons care needs at the time of the inspection.”
critical“The registered manager was unable to sufficiently demonstrate they had kept any records or taken any actions following incidents.”
governance
3 findings
moderate“we identified that whilst they monitored call times on the live system there was no audit in place”
critical“The provider failed to ensure their systems and processes to monitor people's care was effective and could not assure the Commission they had good governance systems in place.”
critical“The provider failed to ensure effective oversight and robust governance which placed people placed at increased risk of harm.”
staff training
3 findings
minor“Staff had not been trained specifically in the MCA, although this was covered in other modules of training they undertook”
critical“Over half of the staff had not received infection control training at all, or not in the past five years.”
critical“We reviewed training records and found significant gaps in staff training.”
safeguarding
3 findings
moderate“We found a number of incidents which were only discussed with an individual's social worker and not the safeguarding team. We were not assured the provider was following their own safeguarding policy effectively.”
critical“People were not kept safe from the risk of abuse or neglect due to the lack of systems, processes and training in place.”
critical“Some staff we spoke with lacked a fundamental understanding of their safeguarding responsibilities.”
missed or late visits
3 findings
moderate“Care was delivered at times in line with staff availability rather than people's choice.”
critical“They are not coming at the correct times, I am left in bed for an average of 15 hours... They put me in bed at 6.30pm when I'd prefer to go to bed at 8pm.”
moderate“How long they are there is a big issue at the moment. Carers only getting 30mins, instead of an hour.”
consent capacity
2 findings
moderate“People's records did not contain clear information about their capacity...no records of mental capacity assessments or best interest decisions”
moderate“There was no best interest decision visible on documents we reviewed. We requested copies of best interest decisions from the registered manager with no response.”
staffing levels
2 findings
critical“One relative described a time due to the lack of staff their family member had been left without a lunch time call for a whole week.”
critical“The provider failed to ensure appropriate staffing was in place to meet people's preferred needs and to ensure people's safety.”
incident learning
2 findings
critical“We were not assured all notifications for incidents, such as, falls with hospital admissions had been submitted to CQC. We had not received any notifications for the service for 12 months.”
critical“There was no system in place to learn from errors, as these were often not even identified, and there was no evidence of any improvements.”
infection control
2 findings
moderate“The providers infection control policy dated April 2020 had not been updated to include COVID-19.”
moderate“During summer staff never wore PPE, they still never wear aprons, they only wear masks at my insistence. Staff don't change their gloves”
person centred care
2 findings
moderate“The terminology on some care plans were written in a derogatory way. For example, 'do not ask person what they want to eat just go in the kitchen and make it'.”
critical“At management level we found evidence of a culture that significantly disregarded the needs of people.”
leadership
2 findings
moderate“The registered manager had no oversight of governance for the service...The registered manager said they did not know this had been implemented.”
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
supervision appraisal
1 finding
moderate“I haven't had a supervision for 3 years.”
communication with families
1 finding
moderate“I have never been involved in any care planning, I have never seen any care plans, I didn't get a reply to my emails with information.”
other
1 finding
critical“We reviewed recruitment records and found a lack of evidence that pre-employment checks were being carried out.”