critical“one person who had diabetes did not have any risk mitigation plan in place around this condition to help staff take the right actions if the person fell ill.”
minor“There was a lack of information in people's care plans about their nutritional needs and preferences.”
moderate“Three care plans stated that the person's health condition 'affects my ADLs' but gave no further explanation. This information was insufficient to inform staff.”
critical“risks associated with people's health conditions had not been assessed and documented in their care records with clear guidance for staff to follow.”
safeguarding
3 findings
critical
“The service did not have a clear safeguarding procedure detailing the local authority's procedure. The provider didn't use the local authority's procedure for raising a safeguarding alert.”
critical“The service did not notify us of two safeguarding allegations as required.”
critical“Systems and processes in place to report, record and investigate any potential abuse were not established and operated effectively.”
staff training
2 findings
critical“Staff training records showed staff had not been trained in key areas, such as first-aid and health and safety.”
critical“staff had not completed training in several mandatory topics such as first aid, food hygiene, MCA and health and safety.”
governance
2 findings
critical“Auditing systems had not identified the issues we found where certain risk assessments around people's health were not in place.”
critical“Management oversight of the service was ineffective and did not identify the issues we found during the inspection.”
record keeping
2 findings
moderate“details of pre-employment checks were not always clearly recorded. For example, the second references for 2 staff members were not dated.”
critical“the service was not maintaining appropriate records of safeguarding concerns and CQC had not been notified of the two allegations of abuse.”
staff competency
2 findings
moderate“Where staff wrote down the wrong answers...there was no evidence that these discussions took place. This meant there was a risk the service did not properly assess staff knowledge.”
critical“Recruitment checks and processes were not always completed in line with procedure to ensure staff were recruited safely.”
consent capacity
2 findings
moderate“Senior staff understood the MCA, but had signed consent on behalf of people on several documents or typed the person's signature.”
moderate“not all staff we spoke to were not able to demonstrate an understanding of the MCA and records showed staff had not completed training”
missed or late visits
2 findings
critical“One person's night time and morning call were 17 hours apart which was too far apart as they were unable to use the toilet in that time.”
critical“a relative raised a concern about several missed care visits which they told us had previously been reported to the management team.”
incident learning
2 findings
moderate“The local authority told us the registered manager did not respond to their request for further information regarding a substantiated safeguarding alert.”
moderate“Where incidents had occurred, there was no record of management oversight in order to record actions, identify trends and opportunities for learning and improvement.”
supervision appraisal
1 finding
moderate“most staff were not being supervised regularly in line with procedure and most longer-term members of staff had not received an appraisal within the past year.”
medication management
1 finding
moderate“not all staff had their competency assessed within the past year in line with national guidance.”
complaints handling
1 finding
moderate“we found the concerns had not been appropriately recorded in line with procedure.”
person centred care
1 finding
moderate“Care plans and risk assessments lacked details of people's individual risks, preferences and choices.”
leadership
1 finding
moderate“We were not assured of the registered manager's understanding of their regulatory responsibilities.”
infection control
1 finding
minor“not all staff had refreshed their training in infection prevention and control within the past year.”