Note30 Oct 2021
The service was compliant with the legal framework of the Mental Capacity Act and Deprivation of Liberty Safeguards.
Note30 Oct 2021
The provider and management were open and honest with inspectors about challenges and committed to improvement.
Note30 Oct 2021
Regular staff demonstrated good knowledge of their clients' needs and built positive relationships.
Note30 Oct 2021
Staff had received training in key areas such as first aid, dementia, moving and handling, medicines administration, infection control and safeguarding adults.
Note30 Oct 2021
Safe recruitment procedures were in place including DBS checks and written references before staff commenced work.
Note30 Oct 2021
Most people said they felt safe in the company of staff and described care staff as kind, compassionate, respectful and polite.
moderateperson_centred_care30 Oct 2021
There was a lack of information within care records demonstrating an assessment of people's emotional and psychological needs, how to meet them and manage refusals of care.
moderatecommunication_with_families30 Oct 2021
People told us staff were often late and they were often not informed of this. Booked for 7 o clock, but the office starts at 9 o clock so there is no-one to contact when they are late.
criticalleadership30 Oct 2021
A registered manager was not in place. The last manager deregistered in July 2016. There were also two care co-ordinator vacancies.
criticalsafeguarding30 Oct 2021
We saw information in people's records or from incident forms where CQC had not been informed of safeguarding concerns, including alleged physical abuse and suspected financial abuse.
moderateincident_learning30 Oct 2021
There was nowhere on the form to record the outcome, actions taken or lessons learned as a result. Some accidents/incidents had not been recorded in the accidents file.
moderatestaff_training30 Oct 2021
The provider did not have an up-to-date training matrix in place. Due to this it was difficult to see where training had lapsed.
moderatesupervision_appraisal30 Oct 2021
During the inspection, the provider told us they were reinstating supervisions and appraisals since we saw many were out of date.
criticalcomplaints_handling30 Oct 2021
We found many of these issues with timeliness and record keeping had not been fully resolved despite some being raised as early as February 2016.
criticalgovernance30 Oct 2021
We identified several breaches of regulation and examples of poor service delivery which should have been prevented by robust systems of quality assurance and governance.
criticalrecord_keeping30 Oct 2021
We uncovered some evidence of false record keeping when reviewing timesheets and daily records. One care staff had written they had attended two different addresses for the same 30 minute period.
criticalcare_planning30 Oct 2021
Some people were without complete care plans. There was a lack of information recorded on how staff should manage people's emotional and psychological needs.
criticalmissed_or_late_visits30 Oct 2021
Most people and relatives (24 out of 34) said that timekeeping was poor and staff didn't arrive on time and/or stay for the correct amount of time.
criticalstaffing_levels30 Oct 2021
There were insufficient staff deployed to ensure people received a consistent and reliable care service.
criticalmedication_management30 Oct 2021
MARs were in place. However those we reviewed were poorly completed and it was not clear what medicines had been prescribed or when they had to be administered.