moderate“staff's records did not contain any information about training completed since January 2016...no records were currently kept of the in-house training provided.”
critical“staff continued to not have the required training to undertake their role. The provider stated they had difficulties in sourcing relevant training that staff would be able to understand”
critical“Staff last completed manual handling and first aid training courses in 2015. This time the registered manager told us that staff were booked to complete these courses at the end of April 2019.”
care planning
2 findings
critical“risk assessments and care plans were not regularly updated in line with changes in people's needs. Care records were not sufficiently detailed to provide an accurate account of the level of support people required.”
critical“People's care plans had not always identified people's health conditions, communication, nutritional and mobility needs which meant that staff were not provided with guidance to ensure safe care delivery.”
record keeping
2 findings
critical“The provider was in breach of Regulation 17 of the HSCA 2008 (Regulated Activities) Regulations 2014. Accurate and complete records were not maintained in regards to people's care and staff training.”
critical“Risk assessments had not identified individual risks to people in relation to their mobility, nutrition and daily activities. Information was not available on how to mitigate the potential risks.”
governance
2 findings
critical“the provider did not have robust systems in place to check the quality and completeness of care records.”
critical“There were no quality assurance processes in place to review the quality of people's care records and to identify improvements required.”
medication management
1 finding
moderate“People's care records did not state what medicines people were taking, when they should be taken and what dose. Therefore there was a risk that staff could not adequately check or prompt people to take their medicines.”
supervision appraisal
1 finding
moderate“staff had not received regular and frequent supervision”
staff competency
1 finding
critical“All three staff that we spoke to could not tell us what the MCA was about… two out of three staff could not tell us what types of abuse they should look out for.”
safeguarding
1 finding
critical“Staff's understanding about safeguarding and the Mental Capacity Act 2005 (MCA) was limited and some of the training refresher courses had not been delivered since 2015.”
leadership
1 finding
moderate“The registered manager was only aware of death and safeguarding related statutory notifications that they had to submit to CQC.”
end of life care
1 finding
minor“Care plan's continued lacking information related to people's cultural and religious needs and their end of life wishes.”