moderate“calls were not delivered at agreed times and they were not always informed if staff were running late... time keeping was an issue with carers coming within a 2-hour window”
care planning
1 finding
critical“Care plans and risk assessments were not completed in sufficient detail where a person had additional health needs or risks associated with their care.”
medication management
1 finding
critical“People were at risk of not receiving their medicines safely. Training and oversight of staff's medicine practices were not sufficiently robust.”
staff competency
1 finding
critical“medicine competencies were not completed on a regular basis and not all staff had spot checks to observe them administering medicines”
staff training
1 finding
moderate“Access to external training and role specific training was limited. There were no champions or train the trainers amongst the staff team.”
governance
1 finding
critical“The provider had failed to ensure the service was always well planned and well led in the interests and safety of people using the service. This was a breach of regulation 17”
leadership
1 finding
critical“The managing director and registered manager did not have sufficient oversight of the service.”
safeguarding
1 finding
critical“some notifications had not been referred to CQC in a timely way”
incident learning
1 finding
moderate“Learning from incidents was not sufficiently robust as there was limited analysis and understanding of why incidents occurred and how they could be reduced.”
consent capacity
1 finding
moderate“The service was not working in line with the principles of MCA... mental capacity assessments were not in place as required.”
supervision appraisal
1 finding
moderate“Staff spot checks were conducted by a senior member of staff when they were covering a care call with another carer. This meant there was not sufficient time or privacy”
communication with families
1 finding
minor“Some people said they had minimal contact with the office and not all remembered receiving a survey or review of their care.”
complaints handling
1 finding
minor“this information had not been collated and there was no mechanism in place to feedback to people using the service to tell them what improvements had been made”
record keeping
1 finding
moderate“This instruction was not dated. Further down the care plan it stated they could sit in their own chair for up to 4 hours but gave no details of repositioning. This information was conflicting”