critical“Governance and performance management was not always reliable and effective. Systems were not regularly reviewed. Risks were not always identified.”
moderate“Although some audits were being completed, they were not robust in identifying all gaps and errors.”
critical“The governance structure in place was not effective at monitoring the quality and safety of the care provided. The provider had no effective oversight of the quality of care being provided.”
critical“Care reviews and quality control audits were disorganised and significantly behind schedule. medicines administration and daily logs had not been systematically audited for over three months.”
care planning
3 findings
critical
“One person had an identified risk of choking but their nutrition and hydration risk assessment stated they were not at risk.”
critical“One person had a grade 1 pressure sore earlier in the year, but there was no reference to this in their care plan or risk assessment.”
moderate“one person who was at risk of developing pressure ulcers, did not have an appropriate skin care risk assessment or care plan.”
record keeping
3 findings
moderate“Care records were not always updated following reviews with people who used the service and/or their relatives or following identified changes in need.”
moderate“When staff had indicated they had raised an incident by either ringing the office or the on-call duty staff member, a contemporaneous note of the action taken had not been made.”
critical“Accurate, complete and contemporaneous records had not been kept in respect of each service user in the carrying on of the regulated activity.”
incident learning
3 findings
moderate“Records for keeping track of specific incidents were not always up to date and accurate, which did not allow oversight into their management.”
critical“Incidents had not always been reported for investigation and where they had been, not investigated. This is important so that lessons can be learnt to prevent incidents to people's safety from re-occurring.”
minor“They did not have a systematic recording process for analysing incidents, outcomes and themes, nor lessons learnt for future practice.”
medication management
3 findings
critical“Medicine administration records (MAR) did not show people had received their medicines as prescribed. We found several gaps in these records that had not been identified for investigation.”
critical“MAR charts we viewed had not been audited and so it was unknown if these were recording errors or represented administration errors.”
moderate“There were no separate protocols for 'as required' (PRN) medicines.”
safeguarding
2 findings
moderate“The safeguarding log contained incidents which were not referred to the Local Authority for safeguarding as they did not fit the criteria and were not always notifying CQC.”
critical“Staff had raised an allegation claiming a member of staff had verbally abused a person using the service. They did not refer this to the local authority safeguarding team or CQC as is required.”
infection control
1 finding
critical“Five of the nine people/relatives we spoke with told us staff did not always wear the relevant personal protective equipment (PPE) to reduce the spread of infection.”
staff competency
1 finding
critical“A DBS was performed for one staff member in August 2018. This showed the staff member had been convicted of a criminal offence in 2016. No assessment of the risk this may pose to people was conducted.”
staffing levels
1 finding
moderate“A relative told us, 'They (staff) come about an hour later because they have been given extra calls to deal with. Sometimes they have turned up just as I am about to dish up lunch.'”
leadership
1 finding
moderate“Four staff said they did not feel fully supported. They stated they did not feel listened to or valued and that concerns they raised were not investigated or taken seriously.”
communication with families
1 finding
moderate“A person said, 'I do have a problem with the office. I am not told who I am getting, and they are constantly changing the rota. I must do the ringing around to find out who is coming.'”
supervision appraisal
1 finding
moderate“Staff had not been consistently provided with regular supervision (planned for a minimum of three times annually).”
consent capacity
1 finding
moderate“Mental capacity assessments had not always been carried out where there was evidence of fluctuating or impaired mental capacity.”