Note18 Jun 2025
The registered manager was passionate about providing a high standard of care and acknowledged areas for improvement.
Note18 Jun 2025
People and families gave positive feedback about care staff, describing them as kind, friendly and respectful.
Note18 Jun 2025
All people and relatives confirmed staff wore full PPE throughout the pandemic.
Note18 Jun 2025
Changes to care practice were put in place when things went wrong, such as a new policy for hospital discharges.
Note18 Jun 2025
Systems were in place to investigate and monitor safeguarding concerns, with staff proactively raising concerns with the local authority.
Note18 Jun 2025
Staff worked in partnership with other health and social care professionals.
moderateleadership18 Jun 2025
The registered manager had no oversight of governance for the service...The registered manager said they did not know this had been implemented.
moderaterecord_keeping18 Jun 2025
Care plans shared with us had historic information in that was not relevant to the persons care needs at the time of the inspection.
moderatemissed_or_late_visits18 Jun 2025
Care was delivered at times in line with staff availability rather than people's choice.
moderateconsent_capacity18 Jun 2025
There was no best interest decision visible on documents we reviewed. We requested copies of best interest decisions from the registered manager with no response.
moderateperson_centred_care18 Jun 2025
The terminology on some care plans were written in a derogatory way. For example, 'do not ask person what they want to eat just go in the kitchen and make it'.
moderateinfection_control18 Jun 2025
The providers infection control policy dated April 2020 had not been updated to include COVID-19.
moderatesafeguarding18 Jun 2025
We found a number of incidents which were only discussed with an individual's social worker and not the safeguarding team. We were not assured the provider was following their own safeguarding policy…
criticalincident_learning18 Jun 2025
We were not assured all notifications for incidents, such as, falls with hospital admissions had been submitted to CQC. We had not received any notifications for the service for 12 months.
criticalstaffing_levels18 Jun 2025
One relative described a time due to the lack of staff their family member had been left without a lunch time call for a whole week.
criticalgovernance18 Jun 2025
The provider failed to ensure their systems and processes to monitor people's care was effective and could not assure the Commission they had good governance systems in place.
criticalcare_planning18 Jun 2025
People's safety needs associated with their health conditions were not always effectively assessed or detailed in their care plan. We found not all risks were recorded.
criticalmedication_management18 Jun 2025
The provider did not complete any medication audits for the electronic records. This meant they were not aware or managing discrepancies with medicines.
Note18 Jun 2025
Infection control training completed; staff wear appropriate PPE during calls
Note18 Jun 2025
Incident investigation processes now in place; registered manager reviews concerns and identifies improvements
Note18 Jun 2025
Registered manager actively sought feedback via questionnaires and took action on results
Note18 Jun 2025
Supervision and appraisals now in place; staff feel supported by management
Note18 Jun 2025
Call consistency improved; staff ring ahead if running late and calls are no longer being missed
Note18 Jun 2025
Safeguarding training completed; staff understood responsibilities to protect people and escalate concerns
Note18 Jun 2025
Safe recruitment practices implemented with DBS checks carried out on all staff
Note18 Jun 2025
Medicines administration improved; staff completed medicines training and had competency regularly checked
minorstaff_training18 Jun 2025
Staff had not been trained specifically in the MCA, although this was covered in other modules of training they undertook
moderategovernance18 Jun 2025
we identified that whilst they monitored call times on the live system there was no audit in place
minormedication_management18 Jun 2025
there remained very little information for staff, such as detailed protocols [for 'when required' medicines]
moderateconsent_capacity18 Jun 2025
People's records did not contain clear information about their capacity...no records of mental capacity assessments or best interest decisions