moderate“management team were unable to confirm to the inspection team, prior to and during the inspection, an accurate number of people receiving personal care.”
minor“staff should record full names when completing notes of care visits... where two staff attended a care call, only one staff member signed the visit for both care staff.”
critical“The person's care and risk assessment did not reflect the person's current care package and detailed guidance was not provided to care staff to support the person's PEG feeding regime.”
moderate“concerns or errors noted were not logged or analysed for trends”
governance
3 findings
critical
“the management team did not have sufficient oversight of ensuring documentation legally required for all staff was in place, such as references and up to date visa documentation.”
critical“Managerial oversight of a particularly complex care package was lacking as the registered and deputy manager were unaware that care staff were carrying out complex care tasks.”
minor“Complaints were not analysed for trends to identify if improvements could be made in particular areas”
care planning
3 findings
minor“We found one instance of a care plan not having been updated following a reduction in a person's package of care.”
moderate“One person's manual handling risk assessment last completed in February 2016 stated they were unable to walk and used a wheelchair. However the person's care assessment completed in February 2017 referred to the person using a walking aid.”
critical“person's risk assessment and care plan which had been completed in September 2015 had not been reviewed or updated to address the person's pressure sore”
person centred care
2 findings
minor“One person told us that they had requested a male carer which had not always happened. We saw that people's gender preferences were not documented in people's care assessments.”
minor“In all care records reviewed the information contained in the section ['Things I would like to achieve'] was the same...This was not person centred and required amendment.”
staff training
2 findings
critical“Training records confirmed that training in PEG care was last provided in July 2015...training had not been provided and the lead carer...was instructing care staff in the care tasks.”
moderate“17 members of staff had not received any mandatory training since 2012, 2013, 2014 and early 2015”
consent capacity
2 findings
moderate“We found instances of consent forms signed by relatives where their legal authority to do so was not documented.”
critical“consent forms were signed by relatives. Care files did not contain details as to why the person receiving care had not signed their care plan”
staffing levels
1 finding
critical“one staff member working did not have permission to live or work in the UK... a further six staff working for the service who did not have permission to work in the UK being identified.”
staff competency
1 finding
critical“Staff had not received training to carry out PEG care and the lead carer was training other care staff in these tasks.”
medication management
1 finding
critical“staff member administering the medicine recorded that they had supported the person to take seven tablets every morning, however the medicines list...stated that the person took six tablets every morning”
incident learning
1 finding
moderate“Accidents and incidents were recorded, however actions, outcomes and learning from accidents and incidents was not always identified”
safeguarding
1 finding
moderate“registered manager had not informed the CQC of two safeguarding referrals made to the local authority”