critical“Systems and processes were not established and operated effectively to protect people from the risk of abuse. This placed people at risk of harm. This was a breach of regulation 13.”
critical“a person who had been in receipt of one to one care had fallen and sustained an injury. This was not recognised within the agency as a safeguarding incident”
governance
2 findings
critical“Systems and processes had not been established and operated effectively to assess, monitor, and improve the quality and safety of the services provided.”
critical“the registered manager and the provider did not yet fully understand their regulatory responsibilities...These shortfalls are a continued breach of Regulation 17”
complaints handling
2 findings
critical“One person said, 'If I made a formal complaint, I'd be frightened that they'd pull out of my care and as I like my current regular care worker, I don't want to risk it.'”
moderate“There was no record of any complaints having been received...We could not see evidence of investigation or that people had been provided with a written outcome”
medication management
2 findings
moderate“There had been no auditing on medicines completed since March 2023. This placed people at the potential risk of not receiving their medicines as prescribed.”
moderate“care plans did not always document the arrangements in place for PRN or as and when medicines and the circumstances in which staff should administer.”
care planning
2 findings
moderate“People told us they did not always have access to their care plans or involvement in reviews. 'I don't have a care plan as far as I know.'”
moderate“Moving and handling plans were not specific and did not give staff step by step guidance. One person told us, 'Some [staff] handle you quite roughly as they pull you from side to side.'”
incident learning
2 findings
moderate“People told us of accidents and incidents which had not been recorded, creating a risk not all potential safeguarding concerns were being identified and escalated appropriately.”
moderate“A record was not maintained of missed calls...Some incidents and accidents were recorded but not all and there was no clear system in place to identify learning.”
record keeping
2 findings
minor“The language used to describe people in some care records was not always positive and respectful, including describing people as 'moody' or 'manipulative'.”
moderate“a member of staff had been the subject of concerns but there was no record on their staff file of any concern, statements or outcome.”
person centred care
1 finding
critical“Visits were scheduled to meet the needs of staffing availability and not people's preferences, which could impact on people's dignity.”
staffing levels
1 finding
critical“Sufficient numbers of suitably qualified, competent, skilled and experienced staff were not deployed. This was a breach of regulation 18.”
staff training
1 finding
moderate“Practical moving and handling training was out of date for 10 of 25 staff. Staff did not receive specialist training in supporting people with a learning disability and or autistic people.”
missed or late visits
1 finding
moderate“Analysis of a sample of call monitoring data showed 31% of visits were not logged. There was no system or log in place to explain the reason for this.”
end of life care
1 finding
moderate“The service did not consistently engage people in planning their end of life care or demonstrate how they record and act on individual wishes.”
leadership
1 finding
moderate“The registered manager was not in the country at the time of the inspection and failed to respond to multiple requests to contact the CQC.”
infection control
1 finding
minor“staff using PPE during our visits to people in their own home but saw that they did not always change their PPE between tasks which is not good practice.”