moderate“Quality assurance systems had not identified issues around the timeliness and duration of care visits which we found at this inspection.”
moderate“Referrals were being appropriately made, however not all had been notified to CQC.”
record keeping
2 findings
moderate“One person had a risk of falls, but this wasn't reflected in their risk assessment. The same person's continence care plan did not refer to their catheter.”
minor“a full work history had not been taken for each member of staff”
staffing levels
1 finding
critical“Staff were required to work particularly long hours with limited days off. This placed people at an increased risk of harm due to the impact of staff working long hours.”
missed or late visits
1 finding
critical“Rotas did not account for sufficient travel time to enable care visits to be punctual. Staff did not always stay for the full duration of their visit.”
incident learning
1 finding
moderate“Although we had been assured by the provider that staff were not working potentially unsafe hours, records and feedback showed staff working long hours with limited days off.”
care planning
1 finding
minor“One person's care plan showed they were living with dementia. We looked at their mental capacity assessment and saw this recorded the person as not having this condition.”
communication with families
1 finding
minor“We identified two people were named in the provider's WhatsApp messaging group used by staff to communicate key messages.”
staff competency
1 finding
minor“Feedback from some relatives showed staff were not always skilled in carrying out household tasks such as making porridge and managing boxed medication.”
medication management
1 finding
minor“The guidance to staff on when a person may or may not need their PRN medicines could be improved.”