moderate“Staff did not receive support in line with company policy, which included annual appraisal. Some appraisals had not been completed since we last inspected, even though a plan was in place.”
minor“The operations manager explained that appraisals had not yet been carried out due to unforeseen circumstances.”
moderate“not all staff had received regular supervision. The manager told us, 'We do have sessions – they haven't all been written up, but we do have the conversations.'”
governance
3 findings
moderate“Quality audits and checks had been completed, but some were a little behind in timescales.”
critical
“provider was also running the service from another location in Ashington. This location was not registered as a condition with CQC”
critical“An effective system was not in place to monitor the quality and safety of the service. The manager told us, 'We refer to them but don't complete them'.”
record keeping
3 findings
minor“The management team were not fully clear on what personal care entailed as part of their registration.”
moderate“records did not always evidence the training which had been completed”
moderate“staff sometimes wrote each other notes and left them displayed around people's houses to inform other staff of people's preferred routines. This information had not been incorporated into people's formal care plans.”
staff competency
2 findings
minor“Not all staff had their medicines competencies checked to ensure they were safe to administer medicines. This was currently being addressed.”
moderate“Formal documented checks of these observations however were not completed to demonstrate what areas had been assessed and any areas for action.”
medication management
2 findings
moderate“there were medicines missing from one person's medicines administration record”
critical“the label on the medicine stated not to crush the medicine. Staff had handwritten on the MAR that the medicine could be crushed and put into water.”
consent capacity
2 findings
moderate“Mental capacity assessments had not been carried out for specific decisions for two of the people we visited.”
critical“a decision made in line with MCA principals had not been recorded. There were no management plans in place with details of how and when these decisions were to be reviewed.”
complaints handling
2 findings
critical“one relative who stated they had made a complaint; however, they had not received a response to their complaint”
minor“informal complaints were recorded in people's individual files. This omission meant there was no system in place to review concerns and informal complaints to identify if there were any trends or themes.”
incident learning
2 findings
moderate“A log was kept of accidents and safeguarding incidents, however, lessons learnt were not documented.”
critical“the provider had not notified CQC of a serious injury. This omission meant an effective system was not in place”
staff training
2 findings
moderate“it was not clear which staff had completed safeguarding training from the training records we viewed”
critical“There was no evidence of induction training being completed. We found the records did not always evidence the training which had been undertaken or demonstrate that competency checks had been completed.”
leadership
1 finding
moderate“Changes to the management team had occurred. This meant leadership had been inconsistent. Leaders and the culture they had not always supported the delivery of high-quality, person-centred care.”
communication with families
1 finding
minor“The complaints policy was not available in picture format, which would help some people.”
safeguarding
1 finding
critical“one specific allegation had not been reported to the local authority in line with the provider's safeguarding policy. The provider had not notified CQC of three safeguarding allegations in a timely manner.”
care planning
1 finding
moderate“Care plans and risk assessments were not always detailed and decisions made in line with MCA principles had not been recorded.”