critical“Quality assurance processes had failed to ensure that improvements made had been sustained. The issues identified were similar to issues identified at the previous inspection in 2021.”
critical“Not all notifications of safeguarding allegations were submitted to the Care Quality Commission (CQC) as is required.”
critical“The provider did not always identify when incidents met the notification threshold. We are concerned they did not understand their regulatory responsibilities.”
critical“The registered manager did not inform the Care Quality Commission of significant events that affect people's safety and wellbeing.”
safeguarding
3 findings
critical
“Although a safeguarding log was in place, it did not always contain the information related to the investigation completed by the local authority.”
critical“Two people had made allegations that care staff had stolen from them. The registered manager had not made referrals to the police.”
critical“We saw records of three safeguarding adults investigations involving the service, about which we had not been notified as required by law.”
incident learning
3 findings
critical“Risks had not been analysed to identify trends so action could be taken to help reduce the risk of recurrence. There were no examples of reflective practice.”
critical“staff and managers were not recording, analysing and reviewing all safeguarding incidents to prevent reoccurrence.”
critical“The registered manager did not undertake any analysis of accidents or incidents to determine trends, or implement changes to improve the service.”
record keeping
3 findings
moderate“Safeguarding records were not kept accurately. Record keeping plays a fundamental part in providing high quality care.”
moderate“The registered manager did not have oversight of audits, such as care plans and risk assessments.”
critical“Records relating to the care of people were not fit for purpose, they were not always completing records accurately. Regulation 17(1)(2)(c).”
missed or late visits
2 findings
critical“one 30-minute morning call was scheduled for 06:00am but carers did not arrive until 08.23am. The call then only lasted for nine minutes.”
critical“One person was scheduled to have a staff member visit for 45 minutes from 8am. Their call log for 1 September 2016 showed that the staff member visited at 5:32pm for less than one minute.”
care planning
2 findings
moderate“Care plans did not always promote personalised care and lacked information for staff to meet people's needs safely.”
critical“The remaining four care plans we viewed were for people whose support was funded by the local authority...were incomplete, did not contain appropriate information about people's preferences.”
consent capacity
2 findings
moderate“Two people whose care plan recorded they had dementia did not have a mental capacity assessment in relation to the receipt of care and support.”
critical“Three of the care plans we viewed did not make reference to the person's capacity to understand and make decisions about their support at all.”
medication management
1 finding
critical“MARs lacked critical information such as people's address, names, date of births, dates were incomplete and no information about allergies was recorded.”
person centred care
1 finding
moderate“Care plans were not always personalised to include people's preferences, wishes, needs in key areas such as communication, life history, mental capacity, mobility.”
staffing levels
1 finding
critical“a person required two care workers to deliver their care safely, but records showed the staff did not attend at the same time.”
supervision appraisal
1 finding
moderate“Some staff were not having regular supervision and this could impact on the quality of care and support people received.”