Note30 Oct 2021
Previous breaches of Regulations 11, 12, 17 and 18 all remediated since October 2016 inspection
Note30 Oct 2021
Service provided additional support at Christmas including meals and extended visits for isolated people
Note30 Oct 2021
Positive staff culture with regular supervision, spot checks, appraisals and accessible management
Note30 Oct 2021
Strong person-centred care plans including cultural, religious, language and social activity needs
Note30 Oct 2021
Robust online quality assurance system monitoring care records, medicines, staff files, complaints and safeguarding
Note30 Oct 2021
Locality-based staffing reduced travel time between calls, minimising late or missed visits
Note30 Oct 2021
Mental Capacity Act compliance improved since previous inspection; capacity assessments recorded and consent obtained
Note30 Oct 2021
Staff received annual safeguarding refresher training and demonstrated understanding of abuse recognition and reporting
Note30 Oct 2021
Medicines administration records accurately completed, regularly audited, and staff competency assessed via spot checks
Note30 Oct 2021
Personalised, up-to-date risk assessments with clear guidance for staff on managing and minimising risk
Note29 Jan 2020
Medicines administration records were accurately completed and spot checks were conducted.
Note29 Jan 2020
Complaints were managed in line with policy and people felt listened to.
Note29 Jan 2020
Staff received induction training, regular supervision, and could request specialist training based on individual need.
Note29 Jan 2020
Staffing levels were sufficient and people reported being seen by consistent, familiar care workers.
Note29 Jan 2020
Care workers had good knowledge of people's cultural backgrounds, religions, and personal histories.
Note29 Jan 2020
People and relatives gave consistently positive feedback about care workers, noting kindness, compassion, and respect for privacy and dignity.
Note29 Jan 2020
Recruitment procedures ensured only suitable staff worked at the service, with thorough documentation including DBS checks and references.
Note29 Jan 2020
Staff demonstrated a good understanding of safeguarding procedures and how to recognise and report abuse.
moderatemedication_management29 Jan 2020
any discrepancies in recording or any errors in the administration of medicines may not have been identified or addressed for a significant period of time after the incident occurred.
moderateperson_centred_care29 Jan 2020
care records contained very limited details about people's needs or preferences...very limited or no information about people's life history or preferences in relation to how they wanted their care to…
moderatesupervision_appraisal29 Jan 2020
appraisals were not conducted regularly...some staff had not had an appraisal for over two years.
criticalsafeguarding29 Jan 2020
We identified two safeguarding incidents that had not been reported to CQC as required so that these could be assessed and action taken where appropriate.
criticalgovernance29 Jan 2020
did not see evidence of audits or any other monitoring of care records...provider was not assessing, monitoring or mitigating the risks we found to service users.
criticalconsent_capacity29 Jan 2020
care records that were not signed by the person using the service...no indication within the records about whether the person had the capacity to make this decision.
criticalrecord_keeping29 Jan 2020
incomplete or inconsistent record keeping that could have placed people at risk of avoidable harm.
criticalcare_planning29 Jan 2020
some people's care plans and risk assessments were inconsistent and sometimes lacked information.. For example, in one person's care record we found inconsistent records kept with regard to whether th…