Note4 Mar 2023
Notifications about significant events were submitted to CQC and duty of candour systems were in place.
Note4 Mar 2023
Staff had received training in PPE use and people confirmed staff wore masks, gloves and aprons appropriately.
Note4 Mar 2023
The service was working within the principles of the Mental Capacity Act 2005.
Note4 Mar 2023
People felt safe with staff and were complimentary of the care received; staff felt well supported by management.
Note4 Mar 2023
Where issues were identified, root cause analyses were completed and lessons learned to prevent recurrence.
Note4 Mar 2023
Staff knew what to do if they thought someone was at risk and safeguarding referrals were made appropriately; local authority safeguarding team confirmed the service worked well with them.
Note4 Mar 2023
Staff were recruited safely and the registered manager took immediate action to address induction issues identified during inspection.
minorsafeguarding4 Mar 2023
Safeguarding incidents had been investigated appropriately and followed up. However, documentation in relation to these incidents had not always been signed by the registered manager.
minormissed_or_late_visits4 Mar 2023
One person we spoke with said there had been a missed call. Some people commented calls were not always on time and this has meant calls had been very close together.
minorperson_centred_care4 Mar 2023
One person said they did not know if their care plan had changed when their needs changed. Another said an admin person visited and left a care plan which was supposed to have been updated but never g…
moderategovernance4 Mar 2023
Systems to audit quality and safety within the service at branch and provider level were in place but needed some improvement to make sure they covered all aspects of the service.
moderatestaff_training4 Mar 2023
Periods of shadowing for staff new to care were often short and records did not always evidence any follow up with the member of staff to make sure they felt confident in their role.
moderatemedication_management4 Mar 2023
Protocols for administering as needed medicines were not always in place. Some care records on the providers electronic care records system did not always record people's GP and/or pharmacist.
moderaterecord_keeping4 Mar 2023
Care files held in the office were not always easy to navigate with archived records mixed with current records... the system did not contain care plans or risk assessments.
moderatecare_planning4 Mar 2023
Some care plans had not been updated or reviewed for more than one year. This meant there was not always evidence to demonstrate risks to people's health and safety were being effectively assessed.