moderate“A person who was at risk of falls had information missing from their care plan. This placed the person at increased risk of harm as staff did not have necessary information.”
moderate“At our last inspection the provider had not ensured that care plans and risk assessments included the detail necessary for care workers to be able to identify and meet people's needs.”
moderate“Some care plans lacked detail which meant staff did not have the information they needed to provide responsive care.”
safeguarding
2 findings
critical“4 people who either had unauthorised restrictions on their daily life, or paperwork in their file which contained elements of restrictive practice.”
critical
“A staff member who had never worked in care before had been sent on their first call on their own to support a person with complex needs... This resulted in a safeguarding incident.”
governance
2 findings
critical“Systems and processes in place to ensure regular audits were taking place, these did not always improve the quality and safety within the service.”
critical“The provider's systems and processes to assess, monitor and improve the quality and safety of the service provided were ineffective.”
record keeping
2 findings
moderate“Some people's records contained conflicting information, in respect of mental capacity and pain levels. This had not been identified and acted upon by the provider.”
moderate“People's 'daily records', completed by staff when they supported them, did not contain enough detail to show that people's assessed needs had been met.”
staff competency
2 findings
moderate“Staff had received safeguarding training, however, safeguarding concerns were not always identified and escalated to the relevant agencies.”
critical“The provider had not followed their own recruitment procedure and had allowed a new member of staff to start work without police clearance.”
staff training
2 findings
moderate“At our last inspection the provider had not ensured that all the staff employed had received the training they needed to provide effective care to the people using the service.”
moderate“Some people felt that new and relief staff were not trained to the standard of regular staff.”
medication management
1 finding
critical“Medicine counts for 1 person identified multiple medicine doses had been missed, however medication records had been signed by staff to state the person had received all of their prescribed medicines.”
staffing levels
1 finding
critical“Some staff worked excessively long hours, frequently picked up calls on their day off, and worked on care visits in the day before working a waking night shift that evening.”
consent capacity
1 finding
critical“Records for 1 person showed care being delivered to them whilst they were asleep, which meant they did not have the option to refuse if they so wished.”
incident learning
1 finding
moderate“The provider had reviewed a lot of the records we looked at prior to this inspection but had failed to identify the issues we found. Reviews were not sufficiently thorough.”
complaints handling
1 finding
minor“When we inspected it was in need of updating to better explain the role of the local authority, the Ombudsman, and CQC in dealing with complaints.”
communication with families
1 finding
minor“A couple of respondents had said they thought staff at the agency could be better at communicating with them, for example telephone calls were not always returned promptly.”
supervision appraisal
1 finding
moderate“Over a third of staff had not yet had supervision in 2016. This meant staff may not have been getting the support they needed to carry out their roles.”
missed or late visits
1 finding
moderate“There have been lots of times where nobody has turned up. They leave [my family member] on a night shift with nobody to help her.”