minor“The provider had an electronic system in place to monitor staffing levels and timekeeping. However, this was not always effectively used to prevent staff lateness.”
critical“There was a lack of records in respect of audits carried out by the provider and it was therefore not possible for them to demonstrate they had good oversight of the provision of the service.”
critical“Although audits and checks had been undertaken and some shortfalls identified, actions had not always been taken in a timely manner to make the necessary improvements.”
moderate“the registered manager had not identified through care plan checks that risk assessments had not been comprehensively undertaken”
missed or late visits
3 findings
moderate
“I don't seem to have any sort of set times the carers come when they want, and I have no power to sort this.”
moderate“One relative however told us they required two staff to support their family member and sometimes one care worker arrived without a second care worker attending.”
minor“We had a lot of missed calls. One carer will turn up but the other carer did not. That has happened a lot of times before.”
care planning
3 findings
critical“One person's care plan did not reflect an increase of two care calls each day. The plan only referenced the original breakfast call, not the lunch or evening call.”
moderate“People's care plans were not person centred. This was because they did not contain information about how people could be supported with their diverse needs.”
critical“one person's care plan stated they were 'severely bed ridden at the moment'...there was no guidance for staff as to how the person would be moved using the sliding sheet”
record keeping
3 findings
critical“One staff application form dated May 2019 lacked important information...blank sections stating when the staff moved to their current address, lack of national insurance number and no recent employer listed after November 2017.”
moderate“Entries varied as to the effectiveness of the content in stating clearly what had been done and how the person received their care during each call.”
critical“The same person had a history of falls but there was no falls risk assessment...no risk assessment in place to see if they required bed rails”
medication management
2 findings
critical“Competencies completed did not state where the staff was observed administering medicines. For example, one competency form did not have a staff name attached to the form.”
critical“Staff had received medicines administration training but we found one person was supported with their medicines when it was not in their care plan for staff to do this.”
person centred care
2 findings
moderate“There was no information about their background or for instance, where they grew up or events that were important to them that staff could reference.”
minor“there was little detail for example if the person preferred a shower or support to bathe or if there were part of the task they could perform them self”
staff competency
1 finding
moderate“The shadowing assessment forms were not always completed in a robust manner to confirm that the care worker took part in a comprehensive shadowing process.”
safeguarding
1 finding
critical“The registered manager, whilst informing the local authority of safeguarding adult concerns, had failed to inform the CQC. This is a legal requirement therefore the provider had breached the regulations.”
leadership
1 finding
moderate“The provider did not have full oversight of their service...whilst reviewing one person's file we found the care notes of another person who from the content was clearly receiving a regulated activity.”