Note11 Jul 2023
People were engaged and involved; regular telephone questionnaires used to gather feedback
Note11 Jul 2023
Regular communication between management and staff, including spot checks and team meetings
Note11 Jul 2023
Provider worked well with healthcare professionals, community nurses, GPs and local social care services
Note11 Jul 2023
Positive, open culture reported by people, relatives and staff; management responsive to concerns raised
Note11 Jul 2023
Service operated within the principles of the Mental Capacity Act 2005
Note11 Jul 2023
Good infection prevention and control practice; staff had access to PPE and relevant training
Note11 Jul 2023
Staff knew how to recognise and report safeguarding concerns and changes in people's needs
Note11 Jul 2023
People felt safe with staff and described them as caring, kind, respectful and considerate
moderateleadership11 Jul 2023
registered manager provided assurances to CQC prior to the inspection stating all improvements had been completed. However, we identified multiple people did not have an up to date care plan
criticalsafeguarding11 Jul 2023
local authority looked into other concerns of staff unauthorised presence in people's homes...additional staff visiting their homes did not record their attendance on the staff monitoring system
criticalrecord_keeping11 Jul 2023
provider had failed to ensure their governance systems were used effectively and failed to maintain accurate and complete records
moderateincident_learning11 Jul 2023
The provider did not always learn from adverse events in the service and people's feedback. The incidents, accidents, complaints and feedback was recorded but not analysed
moderategovernance11 Jul 2023
incidents, accidents, complaints and feedback was recorded but not analysed to identify any patterns and lessons learnt
criticalgovernance11 Jul 2023
provider had poor oversight of the overall safety and quality of the service...management team could not clarify how staff recruitment checks were monitored and audited
criticalstaffing_levels11 Jul 2023
provider had failed to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons were adequately deployed to attend care visits as planned
moderatestaff_competency11 Jul 2023
Not all staff had received appropriate training in safe management of medicines and competency assessments
moderatestaff_training11 Jul 2023
Multiple staff had out of date training, for example, in safeguarding, health and safety or medicines management. This was not clearly addressed in the provider's action plan.
criticalcare_planning11 Jul 2023
one person had been supported for over 5 months at the time of the inspection and they had no risk assessments in place
criticalcare_planning11 Jul 2023
electronic records for all people we reviewed did not provide any detail around specific risks to people, such as personal care, health needs, moving and handling
criticalmissed_or_late_visits11 Jul 2023
one person's visit was planned for 60 minutes on the morning of the inspection and we saw staff recorded a visit which lasted only 19 minutes
criticalmissed_or_late_visits11 Jul 2023
system report we reviewed stating staff attendance was only 53% compliant with planned timings in April 2023