minor“not all the information about people's care and needs was in one place”
moderate“The provider had obtained only one reference for five of the eight care workers and these were all 'character' or personal references from friends, and in one case from a family member.”
moderate“Staff did not always follow systems to record how they were monitoring people's care. For example, recording fluid intake and recording what happened before, during and after incidents.”
governance
3 findings
moderate“The provider had not always ensured thorough checks were made on staff suitability before they started working at the service.”
critical
“The provider did not always audit medicines management. This meant they had not always identified when improvements were needed.”
critical“The provider had not always notified CQC when things went wrong... records of 2 further safeguarding allegations which had been investigated... had not notified CQC as required.”
medication management
2 findings
critical“Some medicines had passed their expiry date. The staff did not always record the dates they had opened topical medicines such as creams.”
critical“There was no specific guidance for staff about when they needed to administer these [as required medicines]... had not always recorded the reasons for this.”
consent capacity
2 findings
critical“The staff routinely took one person's electronic tablet away from them against their wishes... this restriction had not been properly assessed, planned for, or agreed as in the person's best interests.”
critical“The provider used closed circuit cameras (CCTV)... There were no recorded agreements for the use of this nor an explanation of how the recordings would be stored.”
communication with families
1 finding
minor“some relatives felt they would like clearer information and better communication from the provider”
staffing levels
1 finding
minor“sometimes they did not arrive on time for care visits because of problems with transport... it sometimes led to problems.”
care planning
1 finding
moderate“For 5 people whose care records we viewed, there were only lists of tasks staff needed to complete rather than clear care plans.”
supervision appraisal
1 finding
moderate“There were no records of formal supervision meetings and appraisals for some of the staff. This meant that discussions around their work practice were not being properly recorded.”
staff competency
1 finding
moderate“The provider had not always carried out assessments of their knowledge and competencies... had not assured themselves staff were handling medicines in a safe way.”
incident learning
1 finding
moderate“In January 2023, records showed there was an incident where a person hit another person... The records did not describe what had happened before, the staff response or learning from this.”
safeguarding
1 finding
critical“There were no recorded risk assessments relating to health, equipment used, mobility, skin integrity or eating and drinking for 5 of the people.”