critical“The provider had failed to ensure the governance systems were effective in continually monitoring and driving improvement of the service. This was a breach of regulation 17.”
critical“The provider had not consistently maintained effective oversight of the safety and quality of the service.”
record keeping
2 findings
moderate“The systems to review and monitor staff records were not fully robust. We found gaps in staff recruitment, training and supervision records, that had not been identified in the providers own audits.”
moderate“Risks to the person were not consistently assessed and mitigated. There were no risk assessments in place for staff guidance in these areas.”
supervision appraisal
2 findings
moderate“One staff member that started at the service in December 2021, had no supervision records available. Another that started in September 2022 had no records of having supervision during their induction period.”
moderate“Staff supervision had not been completed in line with the provider's policy and procedure and spot checks were not regularly completed.”
staff training
2 findings
moderate“During the inspection site visit we found records were unavailable of the dates when staff had received training on safeguarding adults and Prevention and Management of Violence and Aggression (PMVA) training.”
minor“Not all staff had completed training in MCA. However, they had been prompted by the provider to complete this.”
staffing levels
1 finding
minor“Rotas showed, and staff told us they worked long shifts and consecutive days which included overnight support. This meant staff may not have rested enough to support the person the next day.”
incident learning
1 finding
critical“Incident reports were not effectively monitored or analysed, to check staff followed personalised risk assessments when responding to incidents of physical violence.”
safeguarding
1 finding
critical“We found 2 incidents of a person self-harming that required hospital treatment. The incidents were not notified to CQC and no records were available of the provider consulting with the safeguarding authority.”
consent capacity
1 finding
moderate“Incident reports did not always record how staff supported people in the least restrictive way possible and in their best interests.”
staff competency
1 finding
moderate“One staff file had a gap of 11 years with no employment history recorded, which had not been identified or explored further at the interview stage.”
infection control
1 finding
moderate“The provider had not ensured staff were routinely polymerase chain reaction (PCR) tested as per government guidance for homecare providers.”
care planning
1 finding
moderate“The care plan was overdue a review, with some information out of date such as dispensing medication which staff no longer supported the person with.”
end of life care
1 finding
minor“End of life wishes in the case of a sudden decline in health had not been discussed as part of the care planning process.”
person centred care
1 finding
minor“The person told us they did not consistently feel well supported, and stated some staff were not completing the domestic tasks required.”