critical“The registered manager failed to report safeguarding concerns to CQC or the local authority. Incident forms showed safeguarding incidents had occurred but not reported.”
medication management
1 finding
critical“Medicines were not managed safely. Peoples electronic medicine administration records (EMARs) were not always up to date and gaps were found.”
care planning
1 finding
critical“Care plans were not regularly reviewed to include relevant and up to date information. Initial assessments were carried, but changes to people's care were not updated.”
governance
1 finding
critical“The provider did not have a robust auditing system in place. Lack of effective oversight failed to identify the concerns we found during the inspection.”
leadership
1 finding
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
incident learning
1 finding
critical“The registered manager failed to learn and improve from incidents. An incident occurred where an agency worker became unfit... led to similar events occurring on two other occasions.”
staff training
1 finding
critical“Staff training had not been completed or kept up to date. Core topics such as safeguarding adults and health and safety were included in out of date training.”
supervision appraisal
1 finding
moderate“supervisions had not been kept up to date, which included spot checks on staff.”
consent capacity
1 finding
critical“Staff were not always following the principles of the MCA. Mental capacity assessments were carried out for people, but they were not always decision specific.”
person centred care
1 finding
moderate“Care plans were not always person centred and included generic information... People were often referred to as 'the individual' rather than their own name.”
staffing levels
1 finding
moderate“There were not always enough employed staff to meet the needs of the service. Outside agencies were used to cover most live-in care calls.”
staff competency
1 finding
moderate“We spoke with the local district nurse involved with this person and they believed staff lacked confidence and training.”
record keeping
1 finding
moderate“evidence and information of visits were not always recorded in people's care plans... care records were not updated so staff had access to relevant and up to date information.”
end of life care
1 finding
moderate“there were no records of staff receiving training in this specialist area of care... End of life care plans were not always completed for people.”
communication with families
1 finding
moderate“People and their relatives told us they hadn't been involved in the care planning for some time... 'Regular reviews don't happen.'”