critical“We asked the manager how they ensured people had consented to their care plans. They replied: "I'm still thinking about that."”
minor“a written contract was in place, which included charges for the service. This was a long and complex document, which was not in an accessible format or language.”
governance
2 findings
critical“The manager told us they weren't sure what a manager or provider audit was, and was obtaining guidance from an external organisation regarding this.”
moderate“Although, some improvements had been made relatively recently, they were on-going, and needed embedding into practice.”
staffing levels
2 findings
critical“We looked at five staff files and found shortfalls in three of them. Some staff only had one reference, and in one staff member's case this was from a friend.”
moderate“Most people and their relatives told us there were issues with staffing levels and staff turnover. This had sometimes resulted in changes in the staff who provided people's care.”
communication with families
2 findings
moderate“The manager told us they were not meeting the requirements of the Accessible Information Standards, and could not meaningfully describe what steps they intended to take.”
moderate“Some people were unhappy about staffing, consistency of staff, and communication with the office.”
staff training
1 finding
critical“The provider's training records showed the only training care staff had been provided with had been within their induction. The induction had been led by the manager, who confirmed...they were not appropriately qualified to deliver training.”
medication management
1 finding
critical“The provider's training matrix showed staff had received no training beyond their induction; the section...for medicines training was blank for all staff.”
infection control
1 finding
critical“Staff had been carrying out personal care during a pandemic without appropriate training.”
safeguarding
1 finding
critical“Some staff told us they had received no training in relation to safeguarding; the provider's own training records showed no staff had received safeguarding training.”
care planning
1 finding
critical“People using the service did not have access to their care plans, and the manager confirmed people had not been involved in developing their care plans.”
record keeping
1 finding
critical“Some people's care plans indicated staff were supporting them with medication, but they did not have medication administration records (MARs) in place.”
supervision appraisal
1 finding
moderate“None of the staff we spoke with had received a one to one supervision with their manager...only three staff had received a one to one supervision.”
incident learning
1 finding
moderate“Records we were provided with indicated there had been two minor incidents in the month preceding the inspection. There was no information available about any lessons learned.”
leadership
1 finding
critical“The manager had been in post for five months at the time of the inspection site visit, but had not submitted an application to register with CQC.”
person centred care
1 finding
moderate“People's views and decisions about care were incorporated in their initial assessments, but they had not been involved in devising their care plans.”
cultural competency
1 finding
minor“Care assessments we checked showed limited information about people's cultural needs.”
missed or late visits
1 finding
moderate“In some cases, there had been issues with lateness, and rushed or missed calls.”